WALLA WALLA COMMUNITY COLLEGE



Walla Walla Community College

Nursing Education

Practicum III

NURS 210

Fall Quarter 2009

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Every effort is made to ensure accuracy in the syllabus at the time of printing. However, the Walla Walla Community College Nursing Education Program reserves the right to change any provision or requirement that is necessitated by circumstances arising during the course. All changes will be provided in writing.

Course Outline

Course Identifier: NURS 210

Title: Practicum III

Credits: 6

Clinical/Lab Hours Per Week: 12

Catalog Description: An application of theory from NURS 200. The focus is on providing care for clients in acute-care, psychiatric settings and in the community.

Prerequisites: NURS 102 and 112 or transition applicant

Co-requisite: NURS 200

Teaching Format: Practicum Assignments

Critical Thinking Activities

Student Presentations

Simulation/Campus Lab Activities

Independent Learning Modules

Workshops

Location: Acute-care and Community Agencies

Course Topics: Central Venous Access Devices

IV Medications

IV Starts and Venipunctures

Blood Administration

Introduction to ECG Interpretation

Evaluation Devices: Standardized Testing

Small Group Participation

Performance Competency

Practicum Assignments

Independent Learning Modules

Skills Performance Testing

Scenario Testing

Course Competencies:

Critical Thinking

1. Demonstrate critical thinking in the use of the nursing process.

2. Demonstrate use of management/leadership principles in the delivery of client/patient care.

Caring

3. Perform interventions in a safe and effective manner.

4. Use therapeutic communication.

Professional Behaviors

5. Demonstrate professional behaviors.

Faculty Contact List

NOTE: Students are encouraged to contact the faculty member responsible for the content area or clinical experience about which they have a question. Contact your faculty advisor for academic concerns and advising. Faculty hours are posted on the Level II bulletin board.

Walla Walla Campus: Nursing Office: 509-527-4240

Clarkston Campus: Nursing Office: 509-758-1702

|Walla Walla Campus |Office |Other |

|Rob Becker - Level II lead faculty |527-4334 |Cell: 509-301-9500 |

|robert.becker@wwcc.edu | | |

|Traci Krebs |527-4245 |Cell: 509-240-0439 |

|traci.krebs@wwcc.edu | | |

|Patti Becker |527-4242 |Cell: 509-301-9680 |

|patricia.becker@wwcc.edu | | |

|Grace Hiner |527-4421 | |

|grace.hiner@wwcc.edu | | |

|Maribeth Bergstrom |527-4240 |Cell: 509-540-5619 |

|Sherri Jones |527-4240 |Cell: 509-540-9424 |

|Jennifer McClintock |527-4240 |Cell: 509-520-0972 |

|Pamela Gisi |527-4240 |Cell: 509-540-5354 |

|Mike Steinke |527-4240 |Cell: 405-535-1450 |

|Mary Huff |527-4240 |Cell: 509-308-1359 |

|Melani Mangum |527-4240 |Cell: 509-520-4140 |

|Clarkston Campus |Office |Other |

|Sue Rammelsberg - level II, Clarkston Coordinator |758-1705 |Cell: 509-595-5731 |

|susan.rammelsberg@wwcc.edu | | |

|Debra Scheib |758-1717 |Pager: 208-799-7559 |

|debra.scheib@wwcc.edu | | |

|Stephanie Carpenter |758-1722 |Pager: 509-750-7040 |

|stephanie.carpenter@wwcc.edu | | |

|Karen Molander |758-1702 | |

|Joyce Drake |758-1702 |208-835-6160 |

|jjjingle2@ | | |

|Jaci Hanvey |758-1702 |208-816-1199 |

|Cathe Unger |758-1702 |208-476-7297 |

Course Expectations:

1. Attend all scheduled learning activities (attendance is taken).

2. No points shall be awarded for missed learning activities.

3. All assignments must be accounted for before progression regardless of score achieved.

4. Required written assignments are to be considered professional documents. Students must use proper, professional terminology, spelling, grammar, punctuation and sentence structure. Slang is not permitted. Grade reductions should be expected if these instructions are not followed.

5. Academic integrity will be strictly enforced. Duplicate answers presented on separate papers will result in a score of zero for the paper(s). Papers (e.g., competencies, care plans, client data sheets, etc.) with plagiarized answers will also receive a score of zero. Any issues of suspected plagiarism or cheating will be referred to the Level II faculty group for consideration of disciplinary action including but not limited to Special Concern with course grade drop.

6. Students must maintain competency for previously learned skills.

7. No student shall copy any documents from a client’s chart unless otherwise instructed by clinical faculty. Confidentiality rules will be strictly enforced.

8. Prior to implementation of any teaching plan, the student must validate the teaching plan and verify appropriateness with instructor or primary RN/preceptor; student must identify resource(s) used in teaching plan development. (Competency 1-C).

9. Note: There is no provision for make-up of missed practicum hours.

10. If unable to attend practicum or arrive on time, the student must notify the main nursing office and the assigned practicum unit prior to the beginning of the assigned practicum shift. Failure to notify the practicum agency and nursing department of an absence or tardy (no call/no show) prior to the start of the assigned shift will result in a “contract” or a “special concern”.

11. Attendance at Pre-Clinical Conference and Hospital Orientations are mandatory. Absence may affect a student’s ability to start a clinical rotation on time.

12. Tests are timed; students will have 1.5 minutes per question for Independent Learning Module (ILM) tests and 3.0 minutes per question for Medication Competency tests.

13. A student arriving late for a test, with an excused tardy, may choose either to take the test with only the allotted time remaining OR take the test at a later time with the 5% point deduction applied per the handbook policy. An excused tardy is one in which the student informs the nursing department that he or she will be late prior to the beginning of class.

14. A student arriving late for a test with an unexcused tardy, will have only the allotted time remaining to complete the test/quiz. An unexcused tardy is one in which the student fails to inform the nursing department of being late prior to the start of class.

15. If there is any discrepancy between answers marked on test hardcopy and Scantron, the Scantron rules.

16. If you are attending practicum at a facility to which you have never been oriented, alert your clinical instructor so that an effort can be made to provide you with adequate orientation to the facility.

17. Invasive procedures/skills (IV start, NG intubation, etc.) may only be performed under the direct supervision of the clinical instructor or a Registered Nurse.

18. Students may not administer intravenous Chemo Therapy.

Point Distribution:

|Assignments |Points Available |Points Earned |

|Independent Learning Modules Post-Tests (5 @ 4 pts ea.) |20 | |

|ILM Skills Practice Day |10 | |

|Skills Lab Practice (minimum 6 hrs to obtain points) |20 | |

|Skills Performance Testing |20 | |

|Journal: CH, MH, - OR - |10 | |

|Professional Presentation (Acute Care) | | |

|Medication Competency Test (20 questions) |20 | |

|Comprehensive Nursing Care Plan |40 | |

|Competency Performance Evaluation |100 | |

|Total |240 | |

Grading Criteria:

1. Competency Performance: Students must achieve a 75% on each performance competency (end-of-quarter mean score) before any other points for course assignments or participation will be considered in the calculation of the final grade. If a student achieves a score below 75% on one competency then the grade for that competency will be recorded as the course grade. All students must achieve a minimum final grade of 75% in order to progress to NURS 211.

2. Skills Performance Testing: Should a student fail to demonstrate competency in the required skill performance, remediation and retesting will be required on the same day of testing and the student will receive a score reduction of 10 points. Should a student fail to successfully perform the required skill a second time, the student will receive a score of zero points and must make an appointment with the Skills Lab staff to demonstrate successful performance of the designated skill. A student absent on the day of Skills Performance testing will receive a score of zero, but must successfully complete Skills Performance testing by appointment with the Skills Practice staff. Failure to successfully complete Skills Performance testing by the end of the quarter will result in the administration of an incomplete (“I”) grade contract. Failure to clear the incomplete (“I”) grade contract by the end of the second week of Winter quarter will result in conversion of the (“I”) grade to a ‘C-‘ grade in NURS 210 and the student will not be allowed to progress.

3. ILM Skills Practice Day: If a skills practice day is missed, the student will receive a score of zero and must arrange to make-up the practice hours with the campus lab staff prior to the start of the clinical rotation. If not completed prior to the beginning of the clinical rotation, the student will not be allowed to practice the required skills in the clinical setting. Should a student not make-up skills practice within one week, the current clinical instructor will be notified and scores on competency 3-B and 5-B will be negatively affected.

4. Skills Practice Lab: A minimum of 6 hours in the Skills Practice Lab (practicing skills) is required this quarter to achieve the designated 20 points. Of those 6 hours, a minimum of 3 hours must be logged during the first half of the quarter to obtain 10 points, and a minimum of 3 more hours must be logged during the second half of the quarter to obtain the remaining 10 points.

• Mid-quarter due date: WW: 10-23-09; CLK: 10-21-09

• End-quarter due date: WW: 11-20-09; CLK: 11-17-09

5. Medication Competency Test: If less than 80% is achieved, the student will be allowed to take one remedial exam covering similar content. If 80% is not achieved on the remedial exam, the student will receive a “C-” grade in NURS 210 and will not be allowed to progress.

6. Contracts/Special Concerns: Students not performing at expected performance/critical-thinking levels will be placed on a practicum contract or receive notice of special concern. More than one special concern may be earned. A grade reduction should be expected for each “special concern”. The amount of grade reduction will be determined on an individual basis by the level faculty.

7. Late papers will receive a one-point deduction per school day as described in the Nursing Student Handbook. A school day is defined as any day the school is officially open.

8. Absent scores: It is the student’s responsibility to follow-up on absent assignment scores.

Independent Learning Modules:

|Independent Learning Modules |Walla Walla |Clarkston |

| |Post-tests |Post-tests |

|NOTE: Independent learning modules must be completed prior | | |

|to skills practice day. | | |

|IV Medications | | |

| |9-30-09 |9-30-09 |

|IV Starts and Venipuncture | | |

|Central Vascular Access Devices | | |

|Blood Administration | | |

|Introduction to ECG Interpretation | | |

Critical Elements:

1. Follow all policies as outlined in Nursing Student Handbook.

2. Maintain confidentiality for clients and agency personnel at all times.

3. Consistently follow the 6 rights of medication administration.

4. Consistently ask for guidance and assistance when unsure or in doubt regarding any issues of care delivery.

5. Communicate in a timely manner with staff and/or instructor regarding abnormal/unexpected client assessment data.

6. Consistently follow Clinical Expectations provided by clinical instructor.

7. Show readiness to perform procedures.

8. Consistently perform all procedures according to agency/college policies.

9. Consistently demonstrate timeliness in meeting professional/course expectations.

Performance Competency

Fall 2009

Grading Criteria

STUDENT NAME ______________________

|Competency |Points |75% |Rotation |Rotation |Mean |

| |Possible |min. |#1 |#2 | |

|1. Demonstrate critical thinking in the use of | 30 |22.5 | | |

|the nursing process | | |+ = | |

|2. Demonstrate use of management/leadership |10 |7.5 | | |

|principles in the delivery of client/patient | | |+ = | |

|care | | | | |

|3. Perform interventions in a safe and |30 |22.5 | | |

|effective manner | | |+ = | |

|4. Use therapeutic communication |20 |15 | | |

| | | |+ = | |

|5. Demonstrate professional behaviors |10 |7.5 | | |

| | | |+ = | |

|Total |100 | | |Total | |

| | | | |( | |

| | + = | |

|Late Point Deductions ( | | |

| |Final Total |( | |

Competency performance self-evaluation

NOTE: Failure to follow the instructions below will result in reduction of points

Your Competency Performance Self-Evaluation must be submitted as follows:

• Word processed, single spaced, 12 font; submitted in two-pocketed folders (not 3-ring binders).

• Student name and date of submission on each page

• Each element of each competency identified (i.e., 1A, 2B, etc)

• Each competency must be limited to 1 page (exception: Competency 1 may be two pages).

• In narrative format, provide one BEST, specific example of how each element of each competency was met per rotation.

• For each of the following elements, each criterion (bullet) must be addressed specifically in sequence: 1-A, 1-C, 3-A, & 4-A.

• All competency self-evaluations must be written in past tense – i.e., what you actually DID – (unless specifically directed otherwise by clinical instructor, e.g., CH/MH rotations)

• Consult your clinical instructor for when Competency Performance Evaluations are due

• Academic integrity will be strictly enforced. All reference resources must be cited. Points will be deducted for quoting or copying a source without proper in-text citations. A reference page must be included.

Clinical Competency Evaluation

Competency performance will be evaluated by incorporating:

• instructor observation of clinical performance

• post-conference participation

• evaluative feedback from others

• written assignments related to clinical experience (journaling, client/patient data sheets, etc.)

• student self-evaluation r/t competency performance

Concept – Critical Thinking

PERFORMANCE CRITERIA

|Competency |Elements |

|Demonstrate critical thinking in the use of |A. Use the nursing process to meet the physiologic, psychosocial and developmental client/patient |

|the nursing process |needs from all age groups |

| |Identify pertinent client/patient data (assessment, labs, diagnostic tests, medical history, etc.) |

| |relevant to selected priority nursing diagnosis |

| |Analyze data and identify the priority nursing diagnosis |

| |Identify a measurable expected outcome related to the priority nursing diagnosis |

| |Identify implemented nursing interventions (minimum 3) with rationales (only one may be r/t |

| |assessment/monitoring) |

| |Evaluate client/patient response to care related to the expected outcome with pertinent recommended |

| |revisions |

| |B. Demonstrate critical thinking in the provision of nursing care |

| | |

| |For the client/patient’s primary diagnosis, integrate knowledge of physiology, pathophysiology and |

| |psychosocial elements with pertinent client/patient history, physical assessment data, medications |

| |and diagnostic testing with guidance |

| |C. Apply teaching/learning principles in addressing client/patient learning needs |

| | |

| |For a selected client/patient or a small group, conduct a teaching-learning project appropriate to |

| |the need(s) of your audience: |

| |Identify a learning need with rationale |

| |Identify an expected learning outcome |

| |Prepare and implement a teaching plan |

| |Evaluate the effectiveness of teaching/learning |

| |D. Complete documentation that reflects beginning organization and application of the nursing process|

| |in addressing specifics of client/patient situation |

| | |

| |Document according to agency policy |

| |Document client/patient education |

| |Develop documentation that: |

| |Addresses client/patient problem(s) |

| |Identifies interventions |

| |Evaluates intervention response |

| |Is legible, complete, accurate and concise |

Concept – Critical Thinking

PERFORMANCE CRITERIA

|Competency |Elements |

|Demonstrate use of management/leadership |A. Manage care for multiple clients/patients |

|principles in the delivery of | |

|client/patient care |Report aspects of client/patient care that warrant intervention by other members of the nursing team |

| |Identify priorities for direct/indirect care for a group of clients/patients |

| |Identify revisions of priorities for direct/indirect care for a group of clients/patients |

| |Demonstrate developing organizational and time management skills in relationship to multiple |

| |clients/patients |

| |Plan and present accurate, pertinent shift reports |

| | |

| |B. Participate in providing care with an interdisciplinary team |

| | |

| |Recognize and participate in the work of an interdisciplinary team to facilitate appropriate |

| |client/patient care |

| |Identify the need for referral to another discipline based on assessment of client/patient needs, |

| |including rationale |

| |Collaborate with interdisciplinary personnel to optimize client/patient care with guidance |

| |Proactively seek to promote and facilitate positive relationships among interdisciplinary team members |

| | |

| |C. Access resources appropriately and manage them effectively |

| | |

| |Identify ways to minimize costs and secure appropriate charges while maintaining quality of care |

| | |

| | |

| | |

Concept – Caring

PERFORMANCE CRITERIA

|Competency |Elements |

|Perform interventions in a safe and effective|A. Administer medications safely, evaluating the need for and the response to prescribed medications |

|manner | |

| |Identify the client/patient condition and focused assessment data for which the medication is given |

| |Identify the drug classification, desired therapeutic effect and potential side effects of medication |

| |therapy specific to the client/patient |

| |Verify the safety and appropriateness of medication orders specific to the client/patient, under the |

| |guidance of a licensed professional |

| |Consistently administer medications following the six (6) rights |

| |Evaluate and document behavioral and physiologic responses to medications |

| | |

| |B. Perform technical procedures safely and effectively |

| | |

| |Communicate purpose, protocol, and rationale for procedures |

| |Demonstrate accountability for technical competency of previously learned and current quarter skills |

| |by completing Independent Learning Modules and practicing in the skills practice lab |

| |Perform previously learned and current quarter skills with supervision and moderate guidance. |

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Concept – Caring

PERFORMANCE CRITERIA

|Competency |Elements |

|Use therapeutic communication |A. Purposefully use therapeutic communication |

| | |

| |Identify the subjective and/or objective data observed in a client/patient relating to an emotional |

| |state (Assessment) |

| |Analyze the above data to correctly identify an emotional state requiring interventional |

| |communication |

| |Develop an expected outcome for the planned therapeutic interaction |

| |Discuss the therapeutic interaction by providing: |

| |A minimum of three examples of statements you made as part of your interaction |

| |The type of therapeutic technique utilized for each example |

| |The patient/client response to each of your statements |

| |Evaluate the effectiveness of the therapeutic interaction in achieving the expected outcome. |

| |Suggest changes to improve the interaction |

| | |

| |B. Describe psychosocial coping mechanisms and adaptation abilities of client/patient and/or |

| |significant others related to illness and stressful life events |

CONCEPT-PROFESSIONAL BEHAVIORS

PERFORMANCE CRITERIA

|Competency |Elements |

|Demonstrate professional behaviors |A. Demonstrate sensitivity and attentiveness to the client/patient, family, and others including their life|

| |experience and cultural/social background |

| | |

| |Demonstrate courteous behavior toward client/patient and family members |

| |Recognize client/patient needs and respond appropriately in a timely manner |

| |Demonstrate appropriate adaptation of nursing care related to cultural and developmental needs |

| |Discuss plan of care with client/patient |

| | |

| |B. Demonstrate accountability and responsibility |

| | |

| |Take responsibility for own learning experience |

| |Demonstrate intellectual humility in professional relationships |

| |Identify own strengths and areas/plan for improvement |

| |Appropriately seek guidance from others when client/patient needs exceed the student’s abilities/ |

| |experience |

| |Utilize feedback to improve performance |

| |Demonstrate punctuality and meet course/program obligations in a timely manner |

| |Attend all clinical /lab experiences (workshops, clinical conference, etc.) and participate appropriately |

| |Incorporate evidence-based findings into nursing practice |

| |Promote safe and effective care in accordance with established standards of care |

| |Demonstrate initiative and accountability by attendance at non-mandated learning (CE) or optional learning |

| |experiences |

| | |

| |C. Practice within ethical, legal, and regulatory guidelines |

| | |

| |Follow agency/school policies and procedures, referring to agency Policy and Procedure manuals as needed |

| |Maintain confidentiality of information |

| |Function within legal scope of practice |

| |Discuss an ethical or legal issue encountered in the clinical setting |

| |Differentiate tasks appropriate to level of training |

| | |

| |D. Demonstrate professional behaviors |

| | |

| |Present and conduct oneself in a professional manner as evidenced by conveying professional courtesy, |

| |diplomacy and tact |

| |Demonstrate self-awareness of behaviors with minimal feedback |

| |Role model professional behaviors to first-year students |

| |Mentor a first-year or pre-nursing student on a consistent basis |

| | |

| |E. Participate in the processes that affect healthcare practice |

| | |

| |Engage in activities to promote the profession of nursing |

| |(e.g., ADN club officer/ committee chair, speaking/ writing to public) |

| |Participate in the provision of non-practicum health-care related activities |

| |(e.g., community service, provide healthcare education, volunteer activities) |

Therapeutic Communication

Instructions for completing Competency #4-A, Use of Therapeutic Communication

Therapeutic communication, as expected for Competency 4-A in Level II, is more than just using therapeutic communication techniques in a conversation – it is interventional. That is, it is purposeful; with a clear, measurable expected outcome. It is based directly on the Nursing Process.

When completing your competency performance self-evaluation (Competency #4-A), include 4 headings, one for each criterion, and pay strict attention to the following guidelines:

Criterion #1:

This criterion asks you to provide a scenario; this includes the first two components of the nursing process: Assessment and Analysis; include a sub-heading for each.

Assessment: Here you must present all the pertinent data you collected – both subjective and objective – that supports the problem you will identify in the next section. This is where you present what you saw and heard that led you to a conclusion about the client’s condition.

Analysis: Here you must demonstrate critical thinking by analyzing the data and drawing a conclusion about what the problem may be. The problem identified must be related to an emotional state, e.g., anxiety, fear, depression, anger, etc., and include a “related to” component, which is the rationale for or the probable cause of the emotional state. For example, “fear related to impending surgery”.

Note: This is not a knowledge deficit, that is, this is not simply a client who needs “information”.

Criterion #2:

Plan: In developing a plan to help your client, you must clearly identify what is the goal (expected outcome) of your interventions. Expected outcomes must be patient-oriented, not nurse-oriented; that is, they must start with “Patient will…” not something like, “To help the patient…” In addition, all expected outcomes must have a measurable component; clearly identify the objective and/or subjective evidence (measurable criteria) that will allow you to know if you achieved your expected outcome. In developing an expected outcome consider their current emotional state and what you hope to achieve after using purposeful, interventional communication.

If a patient is currently: When you conclude, patient will be:

Angry Calm, rational, controlled

Fearful /Afraid Unafraid, accepting of situation

Anxious Calm, tranquil, content

Depressed/Sad Positive, unburdened, satisfied, cheerful

Criterion #3:

Intervention: The intervention of Therapeutic Communication is a twofold process: (1) the patient expresses his/her thoughts and feelings, and (2) the nurse uses therapeutic communication techniques to guide the conversation toward the desired or expected outcome. (Notice that having the patient express their feelings is not the expected outcome, but instead is part of the interventional process of therapeutic communication.)

In this section you must provide (1) a minimum of three examples of statements you made as part of your interventional communication, (2) for each example, identify the type of therapeutic technique utilized (in parentheses), and (3) the patient’s response to each of your interventional statements. (A list of therapeutic communication techniques has been attached for your convenience.)

(cont)

Criterion #4:

Evaluation: In this section you must directly consider your expected outcome and identify (1) if you did or did not achieve the expected outcome, and (2) provide the objective evidence that supports your conclusion, i.e., how specifically you met the expected outcome. Speak to the measurable criteria you identified in your expected outcome. Finally, consider in retrospect what modifications or changes you would like to have made in your communication to be more effective in assisting your client in achieving the desired or expected outcome.

Be honest in your evaluation; not all efforts at therapeutic communication go as planned; do not be afraid to identify examples of non-therapeutic communication you used, with your analysis of why it was non-therapeutic and what you would do differently to improve.

CLIENT/PATIENT DATA SHEET/PLAN OF CARE

(ACUTE CARE)

Student Name _______________________ Date of Care_______________________________________

Instructor Name ______________________ Unit ____________________________ Room # ________

| |For the client/patient's primary diagnosis, integrate knowledge of physiology, |

|Client/patient initials________ Admit date___________ |pathophysiology and psychosocial elements with pertinent client/patient medical history, |

| |physical assessment data, medication and diagnostic testing. |

|Diagnosis (admit) _______________________________ | |

| | |

|Current Surgery (with date)________________________ | |

| | |

|Signs & Sx (on admit)____________________________ | |

| | |

|Medical History_________________________________ | |

| | |

|______________________________________________ | |

| | |

|MD __________________________________________ | |

| | |

|Age ___ Gender____ Allergies____________________ | |

| | |

|CODE STATUS ________________________________ | |

| | |

|Hgt _______Admit wgt_____ Current wgt____________ | |

| | |

|Admission VS__________________________________ | |

| | |

|Activity Level ____________ Diet _________________ | |

| | |

|IV (solution and rate)_____________________________ | |

| | |

|PCA/Epidural (drug/dosage)_______________________ | |

| | |

|Support tubes type/special orders____________________ | |

| | |

|Support System _________________________________ |*Must cite references of resources utilized. |

PLAN OF CARE (complete this section prior to taking care of the client/patient)

|ANTICIPATED PRIORITY FOCUSED ASSESSMENT |PROJECTED PRIORITY NURSING DIAGNOSIS with EXPECTED |PROJECTED NURSING INTERVENTIONS |

|(INCLUDE RATIONALE) |OUTCOME |(minimum 3) |

| |(INCLUDE RATIONALE) |(only 1 r/t assessment or monitoring) |

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| |EXPECTED OUTCOME: | |

CLIENT/PATIENT DATA SHEET/PLAN OF CARE

|Date |DIAGNOSTIC TESTS (labs, Imaging, etc.) |INTERPRET LAB VALUES & DIAGNOSTIC FINDINGS: If |FOR ABNORMAL LAB VALUES, IDENTIFY SIGNS & SYMPTOMS |

|of Test |PERTINENT TO CLIENT/PATIENT CONDITION |abnormal, explain why; if normal, explain why |CLIENT MAY EXHIBIT |

| |(put normal values in parentheses) |pertinent. | |

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*Must cite references of resources utilized.

MEDICATIONS

• List all scheduled medications by TRADE & (generic) names and any PRN medication(s) administered within the last 24 hours.

• Provide client/patient specific rationale for medication (for what specific client/patient condition was this medication ordered – condition should be evident in diagnosis, history, pathophysiology and/or labs)

• Identify allergies to medications and any incompatibilities between medications/IV infusions

• Student must be prepared to discuss mechanism of action, pharmacologic classification, major SE’s, and critical nursing implications

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*Must cite references of resources utilized.

Comprehensive Nursing Care Plan

Grading Criteria

(See attached page for guideline descriptions)

|CONTENT |Points |Points Achieved |

| |Possible | |

|Format (reference page, 1 pt; document format (including in-text citations), 1 pt) |2 | |

|Client/Patient Data Sheet/ Plan of Care |1 | |

|Client/Patient Profile |2 | |

|Weber Health History/Gordon’s Functional Health Patterns |2 | |

|Student Nursing Assessment |4 | |

|Pathophysiology |5 | |

|Diagnostic Tests |5 | |

|Medications |4 | |

|Plan of Care | | |

|Diagnosis |3 | |

|Expected Outcomes |3 | |

|Implementations/Interventions |3 | |

|Rationale |3 | |

|Evaluation r/t Expected Outcome |3 | |

|Total Possible |40 | |

DUE DATES

|Walla Walla |Clarkston |

|11-30-09 |11-30-09 |

APA Format:

The WWCC library website can assist you with APA format at:

Comprehensive Nursing Care Plan

Criteria Description & Instructions

Format

• This is a formal paper and should be word processed with proper spelling, grammar, and terminology.

• It should be single-spaced in a highly organized format with headings, bullets, bolding, columns, etc

• Academic integrity will be strictly enforced. Points will be deducted for quoting or copying a source without proper citation. (See Plagiarism Procedure in Nursing Student Handbook).

• APA 5th edition

• cover sheet

• in-text citations

• running header

• reference page (minimum of three (3) current professional references; current = within last 3 years)

Client/patient Data Sheet / Plan of Care

• Attach the original client/patient data sheet to the Comprehensive Care Plan

• NOTE: The client/patient should be selected from an in-patient setting unless prior permission is obtained from faculty.

Client/patient Profile

• Client/patient data

• Current status

Weber Health History/Gordon’s Functional Health Patterns

• Highlight (with a yellow highlighter) all health history questions that would be pertinent to ask in developing a comprehensive plan of care for this client/patient

Student Nursing Assessment

Complete assessment written in narrative format, with subject headings (as in a client/patient legal chart)

• Subjective Data/Complaints

• Neurological

• Cardiovascular

• Respiratory

• GI

• GU

• Musculoskeletal (include Functional Status: 0=self care, 1=requires use of equipment or devices, 2=requires assistance or supervision from another individual, 3=dependent, does not participate)

• Integumentary (include condition of any invasive site(s), incisions)

Pathophysiology

• Primary (admitting) diagnosis

• Etiology of condition

• Pathogenesis of disease process (written in your own words)

• Textbook symptoms

• Client/patient admitting symptoms

• Integrate pertinent client/patient medical history

Comprehensive Nursing Care Plan

Criteria Description & Instructions (Cont.)

Diagnostic and Lab Tests

• Include date of test with normal values in parentheses

• Include ALL lab and diagnostic test results pertinent to client/patient's condition, pathophysiology and medications (minimum of 4)

• Identify additional lab and/or diagnostic tests you would like to have seen, with rationale

• For pertinent test results, if abnormal, explain why; if normal, explain why pertinent

• Identify expected assessment findings or follow-up measures needed

Medications

• Include ALL scheduled medications and pertinent PRN medications (minimum of 3-4)

• For EACH medication include:

• Trade and (generic) names

• Client/patient specific rationale for medication (why was this medication ordered for this particular client/patient)

• Mechanism of action of medication

• Dose, Route, Time, Frequency

• Pertinent associated laboratory tests

• Common side effects

• Side effects observed

• Pertinent nursing implications of drug administration

• Additional medications you would expect to have seen, with rationale

Plan of Care

• Derive plan of care from analysis of client/patient data

• Identify and prioritize (3) client/patient specific nursing diagnoses (one must be a “Knowledge deficit” diagnosis related to a specific learning need)

• Identify (1) one expected outcome for EACH nursing diagnosis (client/patient centered, timed, measurable, realistic, concise)

• Identify (3) nursing interventions with supporting rationale for each expected outcome (only one per expected outcome may be r/t assessment or monitoring)

• Evaluate client/patient response to interventions in relationship to expected outcome

• Suggest modifications for expected outcome(s) and interventions as appropriate

Comprehensive Nursing Care Plan

CLIENT/PATIENT PROFILE

Client/patient Initials Age Gender Date(s) of Care

Allergies Date of Admission Code Status

Height Weight on Admission Admission VS

Admitting Dx

Current Surgery with date

Pertinent Hx

Therapies and/or Treatments

Group Therapy/Therapeutic Milieu (if applicable)

Current Status

VS this shift

Activity Level Diet Current Weight

Location of IV Site(s) IV Solution(s) and Rates

PCA/Epidural (drug, concentration, dosage)

Support Tube(s) and Location(s)

Intake this Shift (differentiate route(s)) Intake last 24 hours (differentiate route(s))

Output this Shift (differentiate route(s)) Output last 24 hours (differentiate route(s))

WEBER HEALTH HISTORY

GORDON’S FUNCTIONAL HEALTH PATTERNS

BIOGRAPHICAL DATA

What is your name?

Tell me about your background.

When were you born?

What is your ethnic origin?

How old are you?

What level of education have you completed?

Have you ever served in the military?

Do you have a religious preference? Specify.

What is your reason for seeking health care?

Where do you live?

What form of transportation do you use to come here or go other places?

Where is the closest health care facility to you that you would go to if ill or in an emergency?

Reason for Seeking Health Care and Current Understanding of Health

Explain your major reason for seeking health care.

What has the doctor told you regarding your health?

Do you feel you understand your medical diagnosis?

Treatments/Medications

Describe the treatments and medications your have received.

How has your illness been treated in the past?

What is being planned for your treatment now?

Do you understand the purpose of your treatment?

Have you been satisfied with your past treatments?

What prescribed medications are you taking?

What over the counter medications are you taking?

Do you have any difficulties with these medications?

How do they make you feel?

What is the purpose of these medications?

Past Illnesses/Hospitalizations

Tell me about any past illnesses/surgeries you have had.

Have you had other illnesses in the past? Specify.

How were the past illnesses treated?

Have you ever been in the hospital before?

How did you feel about your past hospital stay?

How can we help to improve this hospital stay for you?

Allergies

Are you allergic to any drugs, foods, or other environmental substances (e.g., dust, molds, pollens)?

Describe the reaction you have when exposed to the allergic substance.

What do you do for your allergies?

Developmental History

Do you have any physical handicaps?

Tell me about your health and growth as a child.

Tell me about your accomplishments in life.

What are your lifelong goals?

Has your illness interfered with these goals?

Health Perception - Health Management Pattern

Client/patient's Perception Of Health

Describe your health.

How would you rate your health on a scale of 1 to 10 (10 is excellent) now, 5 years ago, and 5 years ahead?

Client/patient's Perception Of Illness

Describe your illness or current health problem.

How has this affected your normal daily activities?

How do you feel your current daily activities have affected your health?

What do you feel caused your illness?

What course do you predict your illness will take?

How do you feel your illness should be treated?

Do you have or anticipate any difficulties in caring for yourself or others at home? If yes, explain.

Health Management and Habits

Tell me what you do when you have a health problem.

When do you seek nursing or medical advice?

How often do you go for professional exams (dental, Pap smears, breast, BP)?

What activities do you feel keep you healthy/contribute to illness?

Nutritional – Metabolic Pattern

Dietary and Fluid Intake

Describe the type and amount of food you eat at breakfast, lunch, and supper on an average day.

Do you attempt to follow any certain type of diet? Explain.

What time do you usually eat your meals?

Do you find it difficult to eat meals on time? Explain.

What types of snacks do you eat? How often?

Do you take any vitamin supplements? Describe.

Do you consider you diet high in Fat? Sugar? Salt?

Do you find it difficult to tolerate certain foods? Specify.

What kind of fluids do you usually drink? How much per day?

Do you have difficulty chewing or swallowing foods?

When was your last dental exam? What were the results?

Do you ever experience sore throats, sore tongue, or sore gums? Describe.

Do you ever experience nausea and vomiting? Describe.

Do you ever experience abdominal pain? Describe.

Do you use antacids? How often? What kind?

Condition of Skin

Describe the condition of your skin.

How well and how quickly does your skin heal?

Do you have any skin lesions? Describe.

Do you have excessively oily or dry skin?

Do you have any itching? What do you do for relief?

Condition of Hair and Nails

Describe the conditions of your hair and nails.

Do you have excessively oily or dry hair?

Have you noticed any changes in your nails? Color? Cracking? Shape? Line?

Metabolism

What would you consider to be your "ideal weight"?

Have you had any recent weight gains or losses?

Have you used any measures to gain or lose weight? Describe.

Do you have any intolerance to heat or cold?

Have you noted any changes in your eating or drinking habits? Explain.

Have you noticed any voice changes?

Have you had difficulty with nervousness?

ELIMINATION PATTERN

Bowel Habits

Describe your bowel pattern. Have there been any recent changes?

How frequently are your bowel movements?

What is the color and consistency of your stools?

Do you use laxatives? What kind and how often do you use them?

Do you use enemas? How often and what kind?

Do you use suppositories? How often and what kind?

Do you have any discomfort with your bowel movements? Describe.

Have you ever had bowel surgery? What type? Ileostomy? Colostomy?

Bladder Habits

Describe your urinary habits.

How frequently do you urinate?

What is the amount and color of your urine?

Do you have any of the following problems with urinating: Pain?

Blood in urine?

Difficulty starting a stream?

Incontinence?

Voiding frequently at night?

Voiding frequently during day?

Bladder infections?

Have you ever had bladder surgery? Describe.

Have you ever had a urinary catheter? Describe. When? How long?

ACTIVITY – EXERCISE PATTERN

Activities of Daily Living

Describe your activities on a normal day. (Include hygiene activities, cooking activities, shopping activities, eating activities, house and yard activities, other self-care activities.)

How satisfied are you with these activities?

Do you have difficulty with any of these self-care activities? Explain.

Does anyone help you with these activities? How?

Do you use any special devices to help you with your activities?

Does your current physical health affect any of these activities (e.g., dyspnea, shortness of breath, palpations, chest pain, pain, stiffness, weakness)? Explain.

Leisure Activities

Describe the leisure activities you enjoy.

Has your health affected your ability to enjoy your leisure? Explain.

Do you have time for leisure activities?

Describe any hobbies you have.

Exercise Routine

Describe those activities that you feel give you exercise.

How often are you able to do this type of exercise?

Has you health interfered with your exercise routine?

Occupational Activities

Describe what you do to make a living.

How satisfied are you with this job?

Do you feel it has affected your health?

How has your health affected your ability to work?

Sexuality – Reproduction Pattern

1. Female

a. Menstrual history

How old were you when you began menstruating?

On what date did your last cycle begin?

How many days does your cycle normally last?

How many days elapse from the beginning of one cycle until the beginning of another?

Have you noticed any change in your menstrual cycle?

Have you noticed bleeding between your menstrual cycles?

b. Obstetric history

How many times have you been pregnant?

Describe the outcome of each of your pregnancies.

If you have children, what are the ages and sex of each?

Describe your feelings with each pregnancy.

Explain any health problems or concerns you had with each pregnancy.

If pregnant now,

Was this a planned or unexpected pregnancy?

Describe any difficulties or discomfort you have had with this pregnancy.

How can I help you meet your needs during this pregnancy?

2. Male/Female

a. Contraception

What do you or your partner do to prevent pregnancy?

How acceptable is this method to both of you?

Does this means of birth control affect your enjoyment of sexual relations?

Describe any discomfort or undesirable effects this method produces?

Have you had any difficulty with fertility? Explain.

Has infertility affected your relationship with your partner? Explain.

b. Perception of sexual activities

Describe your sexual feelings. How comfortable are you with your feeling of femininity/masculinity?

Describe your level of satisfaction from your sexual relationship(s) on scale of 1 to 10 (with 10 being very satisfying).

Explain any changes in your sexual relationship(s) that you would like to make.

Describe any pain or discomfort you have during intercourse.

Have you (has your partner) experienced any difficulty achieving an orgasm or maintaining an erection? If so, how has this affected your relationship?

c. Concerns related to illness

How has your illness affected your sexual relationship(s)?

How comfortable are you discussing sexual problems with your partner?

Who would you seek help from for sexual concerns?

d. Special problems

Do you have or have you ever had a sexually transmitted disease? Describe.

What methods do you use to prevent contracting a sexually transmitted disease?

Describe any pain, burning, or discomfort you have while voiding.

Describe any discharge or unusual odor you have from your penis/vagina.

What is the date of your last Pap smear?

e. History of sexual abuse

Describe the time and place the incident occurred.

Explain the type of sexual contact that occurred.

Describe the person who assaulted you.

Identify any witnesses present.

Describe your feelings about this incident.

Have you had any difficulty sleeping, eating, or working since the incident occurred?

SLEEP-REST PATTERN

Sleep Habits

Describe your usual sleeping time at home.

How would you rate the quality of your sleep?

Special Problems

Do you ever experience difficulty with falling asleep? remaining asleep? Do you feel fatigued after a sleep period?

Has you current health altered your normal sleep habits? Explain.

Do you feel sleep habits have contributed to your current illness? Explain.

Sleep Aids

What helps you to fall asleep? medications? reading? relaxation technique? watching TV? listening to music?

SENSORY-PERCEPTUAL PATTERN

Perception of Senses

Describe you ability to see, hear, feel taste, and smell.

Describe any difficulty you have with your vision, hearing, ability to feel sensations (e.g., touch, pain, heat, cold), taste foods (salty, sweet, bitter, sour), or smell.

Pain Assessment

Describe any pain you have now.

What brings it on? What relieves it?

When does it occur? How often? How long does it last?

What else do you feel when you have this pain?

Rate you pain on a scale of 1 to 10, with 10 being the most severe pain. (Have a child use the Oucher Scale, with faces ranging from frowning to crying.)

How has you pain affected your activities of daily living?

Special Aids

What devices (e.g., glasses, contact lenses, hearing aids) or methods do you use to help with any of the above problems?

Describe any medications you take to help you with these problems.

COGNITIVE PATTERN

Ability To Understand

Explain what your doctor has told you about your health.

Do you feel you understand your illness and prescribed care?

What is the best way for you to learn something new (read, watch TV, etc.)?

Ability To Communicate

Can you tell me how you feel about your current state of health?

Are you able to ask questions about your treatments, medications, and so forth?

Do you ever have difficulty expressing yourself or explaining things to others?

Ability To Remember

Are you able to remember recent events and events of long ago? Explain.

Ability To Make Decisions

Describe how you feel when faced with a decision.

What assists you in making decisions?

Do you find decision making difficult, fairly easy, or variable?

Role Relationship Pattern

Perception Of Major Roles and Responsibilities In Family

Describe your family.

Do you live with your family? alone?

How does your family get along?

Who makes the major decisions in your family?

Who is the main financial supporter of your family?

How do you feel about your family?

What is your role in your family? Is this an important role?

What is your major responsibility in your family? How do you feel about this responsibility?

How does your family deal with problems?

Are there any major problems now?

Who is the person you feel closest to in your family? Explain.

How is your family coping with your current state of health?

Perception Of Major Roles and Responsibilities At Work

Describe your occupation.

What is your responsibility at work?

How do you feel about those you work with?

What would you change if you could about your work?

Are there any major problems you have at work?

Perception Of Major Social and Responsibilities

Who is the most important person in your life? Explain.

Describe your neighborhood and the community in which you live.

How do you feel about the people in your community?

Do you participate in any social groups or neighborhood activities?

What do you see as your contribution to society?

What about your community would you change if you could?

SELF-PERCEPTION / SELF CONCEPT PATTERN

Perception Of Identity

Describe yourself.

Has your illness affected how you describe yourself?

Perception Of Abilities And Self-Worth

What do you consider to be your strengths? weaknesses?

How do you feel about yourself?

How does your family feel about you and your illness?

Body Image

How do you feel about your appearance?

Has this changed since your illness? Explain.

How would you change your appearance if you could?

How do you feel about other people with disabilities?

COPING-STRESS TOLERANCE PATTERN

Perception of Stress And Problems In Life

Describe what you believe to be the most stressful situation in your life.

How has you illness affected the stress you feel? How do you feel stress has affected your illness?

Has there been a personal loss or major change in your life over the last year? Explain.

What has helped you to cope with this change or loss?

Coping Methods and Support Systems

What do you usually do first when faced with a problem?

What helps you to relieve stress and tension?

To whom do you usually turn when you have a problem or feel under pressure?

How do you usually deal with problems?

Do you use medication, drugs, or alcohol to help relieve stress? Explain.

VALUE-BELIEF PATTERN

Values, Goals, and Philosophical Beliefs

What is most important to you in life?

What do you hope to accomplish in your life?

What is the major influencing factor that helps you make decisions?

What is your major source of hope and strength in life?

Religious and Spiritual Beliefs

Do you have a religious affiliation?

Is this important to you?

Are there certain health practices or restrictions that are important for you to follow while you are ill or hospitalized? Explain.

Is there a significant person (e.g., minister, priest) from your religious denomination whom you want to be contacted?

Would you like the hospital chaplain to visit?

Are there certain practices (e.g., prayer, reading scripture) that are important to you?

Is a relationship with God an important part of your life? Explain.

Do you have another source of strength that is important to you?

How can I help you continue with this source of spiritual strength while you are in the hospital?

Functional Level

(circle one code)

Level 0: Full self-care

Level 1: Requires use of equipment or devices

Level 2: Requires assistance or supervision from another person

Level 3: Is dependent and does not participate

*if additional room is needed, use back of sheet and place under section title.*

STUDENT NURSING ASSESSMENT

Subjective Data

Neurological

Cardiovascular

Respiratory

GI

GU

Musculoskeletal (include Functional Status)

Integument (include condition of any invasive site(s), incisions)

PATHOPHYSIOLOGY

Primary (admitting) Diagnosis

Etiology of Condition

Pathogenesis of Disease Process (written in your own words)

Textbook Symptoms

Client/Patient Admitting Symptoms

Integrate Pertinent Client/Patient Medical History

PERTINENT LABS & DIAGNOSTIC TESTING

|All lab & diagnostic test results |For pertinent test results, if |Identify expected assessment |Identify follow-up measures needed |

|pertinent to client/patient's |abnormal, explain why; if |findings |and/or additional diagnostic tests |

|condition, pathophysiology & |normal, explain why pertinent | |expected |

|medications. Include date of test and| | | |

|put normal values in parentheses. | | | |

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MEDICATIONS

|Medications (Trade &|Client/patient Specific Rationale/|Dose |Pertinent |Common Side |Pertinent Nursing Implications/|

|Generic) |Mechanism of Action |Route |Associated Lab |Effects/ Observed |Additional Medications Expected|

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PLAN OF CARE

|Nursing Dx #1 |Expected Outcome |

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Professional Presentation

(Acute Care)

Instructions:

• Find one (1) article from a current nursing journal that presents a research study supporting specific nursing interventions/practice. Current means written within the last 1-3 years. Consider using the database search through the WWCC library website (this provides access to multiple nursing databases)

• If the article presented is not a true research study, 5 points will be deducted from the earned grade.

• Prepare a 5-10 minute (maximum) presentation of this article using the grading criteria on the following page.

• Prepare a word-processed outline for each member of your audience. The outline should be word-processed, well organized with appropriate headings, and limited to one page. This outline must include major points about the data you are presenting. Include your name at the top and the journal citation (APA format 5th edition) at the bottom. The WWCC library website can assist you with APA format :

• A hard copy of the research article must be provided to your instructor with your outline.

• Your instructor will grade your presentation using the grading criteria found on the next page. It is expected that you will provide a copy of the grading criteria for your clinical instructor.

• Your peers will participate in evaluation of your presentation using the following peer evaluation sheet. Bring copies of the peer evaluation sheet for your classmates to provide you with feedback.

• In the event of an excused absence, the maximum points available would be 2 points for the required handout.

PROFESSIONAL PRESENTATION

GRADING CRITERIA

Begin Time: _________ Presenter: _____________________________

Evaluator: _____________________________

End Time: ___________ Topic: _______________________________________

|Criteria |Comments |Point |Points |

| | |Possible |Achieved |

|Introductory Statement | | | |

|Provides overview of topic | |1 | |

|Addresses how the topic is relative to nursing| | | |

|practice | | | |

|Discussion | | | |

|Topic is developed with reasonable | |4 | |

|thoroughness | | | |

|Content is well focused | | | |

|Pertinence to nursing practice is clearly | | | |

|addressed | | | |

|Summary Statement | | | |

|Presents well-reasoned conclusion supported by| |1 | |

|data presented in discussion | | | |

|Presents recommendations relevant to nursing | | | |

|practice | | | |

|Handout | | | |

|Word-processed; one-page maximum | |2 | |

|Well organized; including title, headings, | | | |

|bullets, etc. | | | |

|Reflects major points of presentation | | | |

|Includes research-based article citation in | | | |

|APA format (5th ed.) | | | |

|Hardcopy of research article was provided to | | | |

|instructor | | | |

|Presenter |Identify strength and weakness of | | |

|Well organized |presenter: |2 | |

|Knowledgeable about topic | | | |

|Connects with audience (eye contact, vocal | | | |

|projection, etc.) | | | |

|Professional attire and demeanor | | | |

|Asks for questions/stimulates dialogue |Teaching aids used: | | |

|Remains within allotted time | | | |

|Total | |10 | |

(If not research-based, subtract 5 pts) (-5)

POST-CONFERENCE PRESENTATION

PEER EVALUATION

Begin Time _________________ Presenter ___________________________

End time ___________________ Evaluator ___________________________

Topic ______________________________

| |Excellent |Good |Needs Some Improvement |Needs Much Improvement |

|Criteria | | |(comments) |(comments) |

| |(comments) |(comments) | | |

|A. Clearly/effectively | | | | |

|communicates the main idea or | | | | |

|theme | | | | |

|B. Information clearly provides | | | | |

|relevance to nursing practice | | | | |

|C. Teaching aids assist in | | | | |

|development of topic | | | | |

|Visible to entire audience | | | | |

|Handout reflects major points | | | | |

|Includes citation of article(s) | | | | |

|used | | | | |

|D. Presenter | | | | |

|Well-organized | | | | |

|Knowledgeable about topic | | | | |

|Connects with audience (eye | | | | |

|contact, vocal projection, etc) | | | | |

|Asks for questions | | | | |

|Remains within allotted time frame| | | | |

|Professional attire & demeanor | | | | |

Identify one “pearl” of information from this presentation you will be able to implement into your nursing practice:

Performance Competency Formative Feedback

Mid-Term – NURS 210

Student Name _____________________

|competency |SUPPORTIVE DOCUMENTATION – INSTRUCTOR EVALUATIVE COMMENTS |

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Individual Conference Session (ICS)

Mid-Term Formative Evaluation – NURS 210

Student Name_____________________

Note: Students are to complete the student section of this form and submit this form with their Competency Self-Evaluation prior to Individual Conference Session (ICS).

|STUDENT SECTION |INSTRUCTOR SUMMARY EVALUATION AND RECOMMENDATIONS |

|My strengths in this rotation: | |

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|The most important thing I learned: | |

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|I give my performance a grade of ____ | |

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Performance Competency Summative Feedback

End-Term – NURS 210

STUDENT NAME________________________

|COMPETENCY |SUPPORTIVE DOCUMENTATION – INSTRUCTOR EVALUATIVE COMMENTS |

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Instructor Signature & Date: Student Signature & Date:

Individual Conference Session (ICS)

End-Term Summative Evaluation – NURS 210

STUDENT NAME_____________________

Note: Students are to complete the student section of this form and submit this form with their Competency Self-Evaluation prior to Individual Conference Session (ICS).

|STUDENT SECTION |INSTRUCTOR SUMMARY EVALUATION AND RECOMMENDATIONS |

|My strengths in this rotation: | |

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|I need to improve on: | |

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|The most important thing I learned: | |

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|I give my performance a grade of ____ | |

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|Rationale: | |

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|Student Signature |Instructor Signature: |

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|Date: |Date: |

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| |Student Signature: |

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| |Date: |

Practicum Skills List

Name ___________________________________

Please update this form regularly AND PRESENT THE UPDATED COPY TO YOUR INSTRUCTOR DURING YOUR ICS AT THE END OF EACH ROTATION. If you have only practiced a skill in the campus lab, please indicate this with a date in the Campus Lab column. If you have actually performed the skill in clinical (on client, staff, instructor), indicate the dates and total number of times in the Practicum column. This will be useful when preparing for Focused Practicum in Spring quarter.

|Skill |Year/Quarter Skill Taught|Skills Practice Lab |Practicum Date |

|Med Administration | | | |

|IM | | | |

|SQ | | | |

|ID | | | |

|IVPB | | | |

|IVP (peripheral) | | | |

|IVP (central) | | | |

|IV start | | | |

|Venipuncture (blood draw) | | | |

|Basic ECG monitoring | | | |

|Central line management & dressing change | | | |

|PortaCath Access/De-access | | | |

|Blood Administration | | | |

|PCA/Epidural pumps (winter quarter) | | | |

|Chest tube management (winter quarter) | | | |

|Catheter insertion | | | |

|Straight/mini/fem | | | |

|Male Foley | | | |

|Female Foley | | | |

|TPN Management (winter quarter) | | | |

|Tube Feeding | | | |

|J/G tube | | | |

|NG tube | | | |

|Kangaroo pump | | | |

|Intermittent gravity | | | |

|Trach care | | | |

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|Naso-gastric Tube | | | |

|Insertion | | | |

|pH analysis | | | |

|Irrigation | | | |

|Removal | | | |

|Dressing Change with wound care | | | |

|Sterile | | | |

|Clean | | | |

|Application of wrap | | | |

|Stoma/ostomy Care | | | |

|Appliance change | | | |

|Hemovac, JP, epidural, etc. (identify type) | | | |

|care of | | | |

|removal | | | |

|Client Admission | | | |

|Discharge with instructions | | | |

|Newborn care | | | |

|Eye ointment | | | |

|Hep B injection | | | |

|Assessment | | | |

|Bath | | | |

|Delivery (birth) | | | |

Community/Mental Health

JOURNALING ASSIGNMENT

|ASSIGNMENT ELEMENTS |POINTS POSSIBLE |POINTS EARNED |

|1. Prepare 2-3 personal objectives specific to your Community /Mental|1 | |

|Health experience. (See “How to build a good objective” on the following | | |

|page) | | |

|2. Daily Journal (narrative format, approx. 1 paragraph for each of the 3 | | |

|items per day) |2 | |

|Describe your day: | | |

|Identify 2-3 things you learned from this experience | | |

|Describe any challenges or problems you encountered and how you dealt with | | |

|them | | |

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|Describe your continued progress toward meeting each of your written | | |

|objectives | | |

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|Analyze your experience (what was good, what went wrong), and what would be | | |

|your professional role in improving your performance and client/patient | | |

|outcomes |3 | |

|3. Describe the role of the nurse in the Community Health/Mental Health |1 | |

|setting during your rotation- (eg teacher, advocate, direct care giver, case| | |

|manager, etc- see community readings) | | |

|TOTAL |10 | |

DUE DATES

|Rotation |Clarkston |Walla Walla |

|#1 |Consult Instructor |Consult Instructor |

|#2 |Consult Instructor |Consult Instructor |

How To Build A Good Objective

1. The subject of your objective (you) is assumed. Thus, either leave out “I will…” or start your objectives like this:

I will:

1. Perform…

2. Demonstrate…

2. Start each objective with an action word:

• perform, demonstrate, provide, educate, care, participate, document, communicate, utilize, use, manage, coordinate, implement, etc.

3. Next, identify the particular skill or intervention you are choosing to perform:

• manage clients, therapeutic communication, technical skills, lab interpretation, professional communication, medication administration, collaboration with other disciplines, patient education, documentation, thinking critically, nursing process, etc.

4. Next, identify the quality of how you want to do it:

• effective(ly), appropriate(ly), efficient(ly), competent(ly), careful(ly), safe(ly), accurate(ly), thorough(ly), precise(ly), complete(ly), correct(ly), pertinent, optimal, etc. (Avoid using “proficiently”; that will require an experience level beyond the bounds of your nursing education).

5. Next, indicate how you will know you achieved the objective; i.e., what will be the evidence that you achieved your objective?

• You must provide specific, measurable, evaluative data.

• Typically, you should state: “as evidenced by…”

• Alternatively, “…per, or, in accordance with agency policy/procedure” works for skills/procedures, as would “minimal instruction required from preceptor.”

• Evidence may also be per “validation by preceptor”.

6. Then, include a time frame:

• “throughout this clinical rotation”, “on a daily basis”, “at least once a day”, “a minimum of six times”, etc.

EXAMPLE:

Implement therapeutic communication effectively as evidenced by problem identification of an emotional state,

(action) (intervention) (quality) (specific, measurable evaluative data)

development of a measurable expected outcome, use and identification of therapeutic communication techniques and evaluation of the therapeutic exchange in terms of the expected outcome at least once each day throughout this clinical rotation (time frame)

7. Lastly, the order of these components may be altered on occasion. For example:

(A) ADMINISTER MEDICATIONS SAFELY AND EFFECTIVELY AS EVIDENCED BY…THROUGHOUT THIS CLINICAL ROTATION

(B) SAFELY AND EFFECTIVELY ADMINISTER MEDIATIONS AS EVIDENCED BY…THROUGHOUT THIS CLINICAL ROTATION

(C) THROUGHOUT THIS CLINICAL ROTATION I WILL ADMINISTER MEDICATIONS SAFELY AND EFFECTIVELY AS EVIDENCED BY…

COMMUNITY/MENTAL HEALTH

PRECEPTOR’S EVALUATION OF STUDENT

NURS 210

EVALUATOR _________________________ DATE ___________ STUDENT __________________________

Please rate the student’s performance on each criterion:

NA = not applicable

1 = needs improvement to meet expectations

2 = meets expectations at a minimum level

3 = meets expectations at an average level

4 = meets expectations at an above average level

5 = meets expectations at an exceptional level

|1. Demonstrate critical thinking in the use of the nursing process. |4. Use therapeutic communication |

| A. Uses the nursing process to meet the |NA 1 2 3 4 5 | A. Purposefully uses therapeutic communication. |NA 1 2 3 4 5 |

|physiologic, psychosocial and developmental needs| | | |

|of clients/patients from all age groups. | | | |

| B. Demonstrates critical thinking in the |NA 1 2 3 4 5 | B. Assists the client/patient and significant support |NA 1 2 3 4 5 |

|provision of nursing care. | |persons to cope with and adapt to situations related to | |

| | |illness and stressful life events. | |

| C. Meets needs for client/patient-focused |NA 1 2 3 4 5 |5. Demonstrate professional behaviors. |

|education using teaching/learning principles. | | |

| D. Completes documentation that is accurate,|NA 1 2 3 4 5 | A. Demonstrates sensitivity and attentiveness to the |NA 1 2 3 4 5 |

|organized, client/patient specific and meets | |client/patient, family, and others including their life | |

|agency requirements. | |experience and cultural/social background. | |

|2. Demonstrate use of management/leadership principles in the delivery | B. Demonstrates accountability and responsibility. |NA 1 2 3 4 5 |

|of client/patient care. | | |

| A. Manages care for multiple clients/patients.|NA 1 2 3 4 5 | C. Practices within ethical, legal, and regulatory |NA 1 2 3 4 5 |

| | |guidelines. | |

| B. Participates in providing comprehensive |NA 1 2 3 4 5 | D. Demonstrates professional behaviors. |NA 1 2 3 4 5 |

|care with an interdisciplinary team. | | | |

| C. Accesses resources appropriately and |NA 1 2 3 4 5 | E. Participates in the processes that affect |NA 1 2 3 4 5 |

|manages them effectively. | |healthcare practice. | |

|3. Perform interventions in a safe and effective manner. |Additional Comments: |

| A. Administers medications safely, evaluating|NA 1 2 3 4 5 | |

|the need for and the response to prescribed | | |

|medications. | | |

| B. Performs technical procedures safely and |NA 1 2 3 4 5 | |

|effectively. | | |

Community-BASED NURSING

CLIENT/PATIENT DATA SHEET/PLAN OF CARE

Student Name _______________________ Date of Care _______________________________

Instructor Name ______________________ Community Site ____________________________

Directions: Complete one sheet per week of your community rotation. Turn into your instructor’s box by 0900 on the first class day following your rotation.

|For one client’s/patient’s primary diagnosis (or potential diagnosis), integrate knowledge of physiology, pathophysiology, and psychosocial elements with |

|pertinent client/patient medical history, physical assessment data, labs and medications. (If labs not available, what would you expect to see). |

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PLAN OF CARE

| PRIORITY FOCUSED ASSESSMENT |PRIORITY NURSING DIAGNOSIS with EXPECTED OUTCOME |NURSING INTERVENTIONS |

|(INCLUDE RATIONALE) |(INCLUDE RATIONALE) |(minimum 3) |

| | |Only one may pertain to assessment |

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| |EXPECTED OUTCOME: | |

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MEDICATION

• Identify one patient medication by TRADE & (generic) name that relates directly to the clients condition.

• Provide specific rationale for medication ( what is most common reason this medication being used)

• Identify pharmacological classification, mechanism of action, major side effects, critical nursing implications and labs pertinent for this medication.

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*Must cite references of resources utilized.

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