BELLINGHAM TECHNICAL COLLEGE
HEALTH OCCUPATIONS
LPN/RN Option
NUR 212
Dev. I.A. Farquhar 8/04
Rev.S. Bouma 7/09
________________________________________________________________________
DEPT/COURSE #: NUR 212
CLOCK HOURS:
4 credits (80 hours)
COURSE TITLE:
Client Care Management Practice I
COURSE DESCRIPTION:
This course provides the student with an opportunity to examine and evaluate current experience,
determine clinical proficiencies, and through the process of portfolio development, expand
clinical nursing expertise within the acute care setting (medical or surgical areas, and mental
health).
STUDENT PERFORMANCE OBJECTIVES (Course Competencies):
Upon completion of this course the student will be able to:
1. PROVIDER OF CARE AND MANAGER OF CARE
 Relate theoretical knowledge of nursing to a given clinical situation.
 Calculate basic nursing math correctly for safe administration of medication and
intravenous fluids.
 Demonstrate progressive skills in communication in order to:
a.
Communicate effectively with pediatric, adults, mother who is in labor, geriatric
patients and their families as wells as patients demonstrating changes in mental
health status.
b.
Communicate effectively with members of the health team, instructor, and peers,
both orally and in writing.
 Use expanded assessment to recognize normal and changing patient health status.
 Demonstrate expanded skills in the nursing process by providing patient/family education
based upon assessed learning needs.
 Report and document assessment, normal/abnormal observations, and nursing care
accurately and in a timely manner.
 Set priorities and organize patient care.
 Implemented a learning plan, based on self evaluation, to expand nursing competence in
a variety of healthcare settings.
 Demonstrates assertiveness skills and resolves conflicts in appropriate manner.
 Demonstrate safe and effective nursing practice.
 Demonstrates ability to problem solve and make sound judgments in caring for patients.
 Evaluate clinical performance and experiences to determine if the practice standards were
met.
 Develop a portfolio for clinical nursing practice.
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2. MEMBER WITHIN THE PROFESSION
 Performs in accordance with acceptable practice as defined by law.
 Follows policies, standards and procedures of:
i)
Clinical facility
ii)
BTC Department of Nursing
 Identifies ethical issues in the clinical setting.
 Acts as patient advocate to meet his/her needs.
 Seeks opportunity for continued learning, self-development, leadership, and management
skills.
 Transition from the LPN role to the RN role by learning clinical decision making skills
while incorporating critical thinking.
METHOD OF INSTRUCTION:
Discussion and Clinical Practice.
REQUIRED STUDENT SUPPLIES & MATERIALS:
 WAC 246-840-575 (3): For Registered Nurse Programs, (f).
 WAC 246-840-700
 NCLEX-RN Examination Test Plan, NCSBN, January 2006 http://www.ncsbn.org/
 NLN Roles and Competencies. (http://www.nlnac.org/manuals/Manual2004.htm).
 Sparks and Taylor’s Nursing Diagnosis Reference Manual
 Davis’s Drug Guide for Nurses
EVALUATION AND GRADING STANDARDS:
Grades will be assigned according to the following criteria:
GRADING GUIDELINES
94%- 100%
91%- 93.9%
88%- 90.9%
85%- 87.9%
82%- 84.9%
79%- 81.9%
=
=
=
=
=
=
A
AB+
B
BC+
76%- 78.9% =
72%- 74.9% =
69%- 71.9% =
66%- 68.9% =
63%- 65.9% =
62% and lower =
2
C
CD+
D
DF
Grades are calculated from total points possible.
1. Implementation of Clinical Portfolio
2. Reflection of Practice through Journal Writing
3. Safe and Effective Nursing Practice
20%
10%
70%
In order to pass this clinical practice, you must receive a minimum of 80 percent and have
functioned safely in the clinical setting.
METHODS OF EVALUATION
Clinical labs will be graded. A student’s grade is based on demonstrating competent clinical
performance and by meeting all clinical objectives satisfactorily. This includes attendance,
professional competency and behavior, and paperwork submitted. A failure is below 80%.
Individual clinical objectives will be developed by the student and used through the clinical
experience. A self-evaluation of student’s clinical performance will be completed to help assess
areas of strengths and weaknesses.
Written and verbal evaluations throughout a student’s clinical experience will be performed by
the team member and instructor. Evaluation conferences may be held as necessary by the
instructor during lab time.
For students encountering difficulty in clinical labs, a performance agreement will be made
between the student and the instructor. This agreement will include measures needed to improve
clinical performance.
Failure in the clinical setting will result when the student practices in an unsafe manner.
Examples of unsafe practice include but are not limited to: violating safe medication
administration procedures, failing to identify clients, failing to use universal precautions, being
abusive to clients or staff, violating ANA Code of Ethics or the Patient's Bill of Rights, violating
the client's privacy, being inadequately prepared for procedures, imposing one’s values upon the
client, or denying the client the right to make decisions about his/her own care. Failure to
provide a therapeutic environment, inadequate preparation for emergency care ('codes'), or
failure to follow agency policies or procedures will also constitute a clinical failure. See
Definitions of Unsafe Clinical Practice for further clarification on the following page.
The final evaluation requires that all objectives have been met and completed in a
satisfactory manner. The clinical instructor will perform the final evaluation.
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Definitions of Unsafe Clinical Practice
OVERRIDING CONCERNS
The student nurse is expected to demonstrate the judgment and behavior necessary to protect
the client from physical and emotional jeopardy and relationships that interfere with comfort and
healing. These areas of potential physical and emotional jeopardy have been identified as areas
of overriding concerns. These basic behavioral expectations in the areas of overriding concerns
are in effect and, therefore, evaluated throughout the quarter in order to ensure safe practice.
Failure in clinical would occur because the student: (a) failed in the area of overriding concerns
due to the seriousness of an incident, or (b) demonstrated a pattern of unsafe behavior, despite
guidance of the instructor.
1. Physical Jeopardy:
Physical care is performing nursing intervention that promotes physical well-being. Any action
or inaction on the part of the student that threatens the physical well-being of a client constitutes
physical jeopardy. For example, failure to identify client (two identifiers are required, such as
name and birthdate), incorrect positioning, unrecognized violation of poor surgical and/or
medical asepsis, such as failure to use universal precautions, failure to wash hands when
indicated, physical abuse and/or misuse of side rails, restraints, assistive devices, equipment, or
improper drug administration.
2. Emotional Jeopardy
Emotional care is assessing the client for values, cultural beliefs, and emotional factors while
caring for a client. Any action or inaction on the part of the student that threatens the emotional
well-being of a client, or increases stress constitutes emotional jeopardy. For example: violation
of privacy, inadequate preparation for a procedure, imposition of own values and beliefs on
clients, denying the client's right to make decisions about his care, or any applicable
infringement of the Patient's Bill of Rights.
3. Clinical Decision Making
Is a problem-solving process by which choices are made in nursing practice using the steps of the
nursing process. Unsafe Clinical decision-making is demonstrated when a student makes a
deliberate decision to omit a critical element within an area of care. Failure in the clinical
decision-making area would occur when a student does not report abnormal findings in a timely
manner, fails to recognize when prescribed therapy should be omitted, or neglects to report the
rationale for a decision made.
Please note: Students are expected to function safely at all times during clinical lab. These are
only some of the examples of unsafe situations and do not represent all examples that can result
in failure by overriding concerns.
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ATTIRE
Clean, Department of Nursing uniforms with the BTC student name tag and patch (on the right)
are to be worn during clinical experience. The name tag and patch must be visible at all times
when students are on the floor. Students who go to clinical lab dressed inappropriately will be
sent home by the clinical instructor receiving an unexcused absence for the day. Please
remember you represent Bellingham Technical College and the profession of nursing.
TARDINESS, ILLNESS, AND UNAVOIDABLE ABSENCES
Students are expected to be at all clinical lab appointments on time. In order for clinical
objectives to be met and for adequate evaluation opportunities to be available, attendance at all
clinical lab experiences is required. Any missed clinical labs must be made up to complete the
hours for the clinical lab at the student’s expense. Absences of more than 10% will be
considered excessive and will prevent the student from progression in the program.
If a student is ill and cannot attend an arranged clinical lab, it is the student’s responsibility to
phone your clinical instructor at least one hour PRIOR to the designated clinical time. The
student is to reschedule the missed hours, if unable to do this the student will be ask to exit the
program.
Please be sure to advise your instructor of any phone, email or address changes that may
occur during the quarter.
PREPARATION FOR YOUR CLINICAL DAY
A.
Arrive at your assigned facility on time, well groomed, and prepared for your
clinical day. You will need the following items for giving patient care:
 Wristwatch with a second hand.
 Stethoscope.
 Appropriate pen for keeping notes.
 Calculator, to figure IV dosages and rates.
 Resource books such as Davis Drug Guide and Spark’s Nursing Diagnosis.
 Penlight for assessment.
 Bandage scissors.
 Pocket notebook or a “brain”.
B.
C.
Take assignments, necessary paperwork and portfolio to every clinical lab.
Organize and prioritize your day on an on-going basis. Keep good notes on your
patients so that you will be prepared for charting and reporting off at the end of your
shift.
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LEGAL RESPONSIBILITIES
A. The registered nurse and clinical instructor must review the medical records of the
client before you are dismissed from the clinical setting
B. The clinical instructor must be present when you change IV’s sites and hang IV
piggybacks or give IV push medications.
E. All medications must be double checked by a RN or clinical instructor prior to
administering.
F. Follow the Six Right rules when giving ALL medications: The Right patient, the
Right medication, the Right time, the Right route, the Right dosage, the Right
documentation. Always check the patient’s ID armband and verify birth date before
giving any medication.
G. You may take phone orders from a physician only if a RN is on an extension phone,
reads back what has been ordered and then co-signs the orders.
H. Changing dressings on central line and any other complex procedures that you have
not performed prior to this clinical experience requires the RN or clinical instructor to
be present.
I. You must notify your clinical instructor immediately of any situation resulting in an
incident report being filled out due to student involvement or error, or of any unusual
event that involves you.
J. Should you need to leave the floor for any reason, you must inform the RN that you
are working with. Should you have to leave the building for any reason you must
inform the clinical instructor.
6
STUDENT ASSIGNMENTS/REQUIREMENTS:
The student will:
1. Assess own practice based on the standards listed in:
WAC 246-840-575 (3): For Registered Nurse Programs, (f).
WAC 246-840-700
NCLEX-RN Examination Test Plan, NCSBN, January 2006
and NLN Roles and Competencies
(http://www.nlnac.org/manuals/Manual2004.htm).
2. Prepare own clinical learning objectives and continue to meet the objective based on their
own portfolio.
3. Choose patient assignments and fill out weekly clinical preparation forms. These forms
will be reviewed by instructor at preconference time.
4. Complete self evaluation twice during the quarter
5. Ask the RN to complete clinical evaluation by team member’s form.
6. Complete clinical journal reflection questions daily and give to clinical instructor by the
end of the shift.
7. Complete an alert sheet daily.
8. Pass final clinical evaluation by clinical instructor.
.
Purpose of Clinical Portfolio
The portfolio is a tool used to validate the acquisition of knowledge and skills congruent with
course expectations and student learning outcomes. The portfolio provides objective evidence
that students have acquired the content and skills through prior learning and/or practice
experiences. The decision to accept the documentation provided is based on determination of the
equivalency of this prior knowledge and skills that the student would be expected to demonstrate
at the completion of a specific course. The portfolio creation process documents the student's
work and accomplishments over an extended period of time. Portfolios are a tool for reflecting
on learning and clinical practice and the discovery of the links between the two.
Guidelines for Portfolio Development
1.
Use a good quality three ring binder for storing of written documents
2.
Portfolio must be typewritten using the following table.
3.
Use a cover page identifying your name and date followed by written assignments and
table of competencies and activities.
Requirements for the portfolio
1. Write two paragraphs describing your current LPN work activities.
2. Based on assessment of the RN standard, describe your strengths and describe the
areas that need strengthening during your clinical experiences.
3. Write at least two paragraphs describing your vision for being a registered nurse for the
next 2 years.
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4. Portfolio development: The following table contains the nursing competencies that you
will need to perform during your clinical experiences. Each quarter these areas should be
expanded. These competencies are based upon the WAC standards for an RN.
5. At the end of this experience the students will evaluate their goal/clinical objectives as a
part of documentation.
Competencies
Goal/clinical
objective
Learning
activities
Nursing Process
 Assessment
 Planning
 Intervention
 Evaluation
Communication
Client Teaching
Delegation/Supervision
Problem-solving/
Decision making
Advocacy
Safe Practice within
the scope of Registered
Nurse
NCLEX study plan
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Knowledge
Base
Documentation
Student Self-Evaluation
The following pages are the student self-evaluation of the clinical experience. The
student is to fill in form and return to clinical instructor by the beginning of the third day and end
of the final day. Although this is a self evaluation, final evaluation grade is up to the discretion of
clinical instructor.
Student Self-Evaluation of Clinical Experience
Student ____________________________________________________Date__________
Codes:
S = SATISFACTORY: Meets clinical performance objectives at a level commensurate with theory and experience
in the program. Functions adequately with minimal direction and guidance. Meets all critical performance
objectives. Seeks assistance when it is needed. Seeks suggestions and benefits from constructive criticism.
U = UNSATISFACTORY/UNSAFE: Is deficient in meeting clinical performance objectives at a level
commensurate with theory and experience in the program. Needs frequent guidance and detailed instruction. Is
unable to consistently apply theory to clinical practice. Is unsafe (see overriding concerns).
NI = NEEDS IMPROVEMENT: Clinical performance – assisted frequently with directive and supportive cues,
needs to move toward being efficient and more independent.
Write the above code for your performance in column provided. Make appropriate comments in
the third column to provide examples of experiences which support the evaluation in the second
column. Provide supporting documentation if appropriate and remember to take into
consideration the WAC’s and the NCLEX Test Plan.
Experience
KEY
Specific examples of instances demonstrating
competence or lack there of.
Nursing Process
1. Assessment: Collects data from a variety
of sources in order to identify nursing
diagnoses.
2. Planning: In collaboration with client
and family, develops plan of care to include
problem identification, nursing
interventions, setting of priorities, needed
services of other health care providers, and
outcome criteria. States appropriate
rationale for interventions
3. Intervention: Provides nursing
interventions safely and competently,
according to a plan and established
priorities.
4. Evaluation: Evaluates effectiveness of
nursing interventions. Revises plan as
necessary.
9
Experience
KEY
Specific examples of clinical competenciesc
Teaching:
1. Identifies educational needs of the client and/or family.
2. Teachs appropriate information related to
identified,social,cultural and education needs.
3. Evaluates effectiveness of the teaching activity.
Delegation/Supervision
1. Makes appropriate assignments after making an
assessment of the abilities of the staff.
2. Provides instruction as necessary.
3. Supervises and evaluates performance of person to
whom the tasks were delegated.
Critical Thinking/Clinical Decision-Making
1. Identifies client care problems.
2. Identifies a number of possible solutions to the
problems integrating other members of the healthcare
team as indicated.
3. Selects an approach to solving the problem and
provides rationale for the selection.
4. Evaluates the effectiveness of the selected solution.
5. Integrates theory with the care of the client.
Professionalism:
1. Exhibits ethical standards that are compatible with the
nursing profession.
10
Clinical Evaluation by Team Member
The registered nurse is to evaluate the student’s performance. This is to provide immediate
feedback on the student’s performance. It is the responsibility of the student to ask the
registered nurse to evaluate his or her performance. The student is to give this form daily to the
clinical instructor. This is part of the student’s clinical grade in determining safe nursing care.
CLINICAL LAB PERFORMANCE
Communication
_____ Professional Appearance
____
Client Teaching
_____ Physical Assessment
____
Delegation
_____ Develop or update patient care plans
Documentation
_____ Problem Solving/clinical decision making
Safe Practice with in the RN Scope
_____
____
Organization/Priority Setting
____
_____
Comments:
S = SATISFACTORY: Meets clinical performance objectives at a level commensurate with theory and experience in the program. Functions
adequately with minimal direction and guidance. Meets all critical performance objectives. Seeks assistance when it is needed. Seeks suggestions
and benefits from constructive criticism.
U = UNSATISFACTORY/UNSAFE: Is deficient in meeting clinical performance objectives at a level commensurate with theory and experience
in the program. Needs frequent guidance and detailed instruction. Is unable to consistently apply theory to clinical practice. Is unsafe (see
overriding concerns).
NI = NEEDS IMPROVEMENT: Clinical performance – assisted frequently with directive and supportive cues, needs to move toward being
efficient and more independent.
□ Satisfactory
□ Needs Improvement
□ Unsatisfactory
Date_________________________Student’s Signature_________________________________
Date_________________________Registered Nurse’s Signature_________________________
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FINAL CLINICAL PERFORMANCE EVALUATION
Student ____________________________________________________Date__________
Codes:
S = SATISFACTORY: Meets clinical performance objectives at a level commensurate with theory and experience
in the program. Functions adequately with minimal direction and guidance. Meets all critical performance
objectives. Seeks assistance when it is needed. Seeks suggestions and benefits from constructive criticism.
U = UNSATISFACTORY/UNSAFE: Is deficient in meeting clinical performance objectives at a level
commensurate with theory and experience in the program. Needs frequent guidance and detailed instruction. Is
unable to consistently apply theory to clinical practice. Is unsafe (see overriding concerns).
NI = NEEDS IMPROVEMENT: Clinical performance – assisted frequently with directive and supportive cues,
needs to move toward being efficient and more independent.
Write the above code for the student performance in column provided. Make appropriate
comments in the third column to provide examples of experiences which support the evaluation
in the second column.
Experience
KEY
Nursing Process
1. Assessment: Collects data from a variety
of sources in order to identify nursing
diagnoses.
2. Planning: In collaboration with client
and family, develops plan of care to include
problem identification, nursing
interventions, setting of priorities, needed
services of other health care providers, and
outcome criteria. States appropriate
rationale for interventions
3. Intervention: Provides nursing
interventions safely and competently,
according to a plan and established
priorities.
4. Evaluation: Evaluates effectiveness of
nursing interventions. Revises plan as
necessary.
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Specific examples of instances demonstrating
competence or lack there of.
Experience
KEY
Specific examples of instances demonstrating competen
Or lack there of
Teaching:
1. Identifies educational needs of the client and/or family,
incorporating social and cultural factors.
2. Develops a plan for teaching that will answer the needs
identified.
Delegation/Supervision
1. Makes appropriate assignments after making an assessment
of the abilities of the staff.
Critical Thinking/Clinical Decision-Making
1. Identifies client care problems.
2. Identifies a number of possible solutions to the problems
integrating other members of the health care team as indicated.
3. Selects an approach to solving the problem and provides
rationale for the selection.
4. Evaluates the effectiveness of the selected solution.
5. Integrates theory with the care of the client.
Professionalism:
1. Exhibits ethical standards that are compatible with the
nursing profession.
PASS [ ]
*FAIL [ ] (Any “U” constitute a failure.)
COMMENTS:
Date
Instructor’s signature____________________________________
Date
Student’s signature_____________________________________________
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Clinical Performance Agreement
BTC Department of Nursing
Student __________________________
Date_____________________
Area(s) of concern:
Statement of the goal:
Description of the activity to achieve stated goal:
What resources are needed to reach stated goal:
Time frame to reach stated goal:
Signatures:
Instructor_____________________Student_____________________
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Bellingham Technical College
Department of Nursing
Student Evaluation of Clinical Instructor
Course____________________________ Clinical instructor_________________________
Quarter:
Fall____
Winter____
Spring____
INSTRUCTIONS: Please choose one number that best describes your experience.
Rate Scale:
4—Strongly Agree
3—Agree
2—Disagree 1—Strongly Disagree
Instructor’s Performance:
Knowledge of the clinical area
Enthusiasm –Inspires quality of work
Plans clinical experiences considering my individual
needs
Encourages questions and comments
Stimulated thought and discussion
Respect and concern for student
Facilitates my increasing independence in the
clinical setting
Clarity in explaining clinical expectations
Is available when requested
Assist me in finding my own solutions
Timely return of student’s work
Offers constructive positive criticism and evaluation
4
4
4
3
3
3
2
2
2
1
1
1
4
4
4
4
3
3
3
3
2
2
2
2
1
1
1
1
4
4
4
4
4
3
3
3
3
3
2
2
2
2
2
1
1
1
1
1
What aspects of this clinical experience contributed most to your learning this quarter?
What aspects of this clinical experience were barriers to your learning this quarter?
If you marked 2 or 1, please give examples of reason for using these marks. What are your
suggests for improvement?
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Bellingham Technical College
Department of Nursing
Clinical Facility Evaluation by Student
Clinical Facility_______________________Nursing Unit_______________________________
Quarter:
Fall____
Winter____
Spring____
INSTRUCTIONS: Please choose one number that best describes your experience.
Rate Scale:
4—Strongly Agree
3—Agree
2—Disagree 1—Strongly Disagree
The unit environment was appropriate to your learning needs:
Number of Patients
4
3
2
1
Variety of Diagnosis
4
3
2
1
Equipment
4
3
2
1
Unit Resources
4
3
2
1
The nursing staff maintained open communication appropriate in meeting your learning
needs
Knowledge level
4
3
2
1
As role models
4
3
2
1
Fostered independence
4
3
2
1
Concern and Respect for me
4
3
2
1
I feel I have benefited from this experience
4
3
2
1
The strengths of this clinical facility were:
What recommendation for improvement within the clinical facility?
If you marked 2 or 1, please give examples of reason for using these marks. What are your
suggests for improvement?
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Date
Student Name
CLINICAL LAB WORK SHEET
Room Number
Sex
Code Status
Admission Date
Allergies
Precautions
Diet
Activities
Vital Signs
Oxygen
Intake and Output
Tubes
Weight
I.V.’s
Medical Diagnoses
Chronic Health Problem unrelated to admission.
Surgeries or diagnostic procedure while in the hospital include dates.
Significant History related to admission. (Signs and Symptoms that cause the patient to be admitted)
Notes: ( e.g. family information and data that will help you to take care of the patient)
Medications—List medication and times to be given. Meds must be listed for 24 hours, not just the shift you are
working.
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CLINICAL LAB WORK SHEET
Room Number 444-1
Sex Male
Code Status Chemical code
Admission Date 1/21/06
Allergies Penicillin, Zocor, Ampicillin
Precautions: Fall
Diet: Cardiac, NAS
Activities Bathroom privilege with
help
Intake and Output every 4 hours
Vital Signs
Every 4 hours
Tubes Foley
Oxygen 1 L/NC keep O2 Sat above
92 percent
I.V.’s D5W at tko and Lasix 3 mg/hr.
site right arm
Medical Diagnoses: MI, CHF and Atrial Fib with PVC, CAD
Weight every day --210
Uses hearing aides
Chronic Health Problem unrelated to admission. Diabetes type 2, COPD, PVD, Cholelithiasis, CAD, hypertension,
venous umbrella device
Surgeries or diagnostic procedure while in the hospital include dates. Heart Catheter 1/21/06
Significant History related to admission. (Signs and Symptoms that cause the patient to be admitted)
Was in the mall and developed chest pain mid sternum. Took 3 NTG and pain subsided. Drove home. Laid down
and slept for 2 hours awoke with chest pain unrelieved with NTG. Wife states that pulse was more irregular; up to 90
it normally runs 60, B/P 160/110, normally 130/70. Took Ativan and MS, pain was not relieved. Called the
ambulance.
12-lead ECG showed atrial fibrillation with ST wave changes indicating a MI. Cardiac Enzymes were elevated. Sent
for heart cath.
Notes: ( e.g. family information and data that will help you to take care of the patient)
Lives with his wife and she is the primary care giver. Has been seeing the cardiac nurse every month for following
CHF and chest pain.
Has been driving and uses canes to walk.
Medications—List medication and times to be given.
1600
1700
1700
2100
2100
2100
2100
Lasix 40 mg. p.o
Digoxin 0.25 mg p.o.
KCL 20 mEq p.o.
Zocor 40 mg p.o.
Cardizem 40 mg. p.o.
Nexium 40 mg p.o.
Surfak 100 mg p.o.
PRN
PRN
PRN
PRN
18
NTG SL
Ativan 0.5 mg
Morphine 2 mg SL
MOM p.o.
Student Name____________________________Instructor_____________________
Steps
Wash Hand
Gather Equipment and prepare tape
Identify Patient/explain procedure
Assess both arms for best vein
Clean area using appropriate technique
Apply tourniquet 2 to 3 inches above site
Immobilize vein
Approach the vein at a 15-25 degree angle
Insert cannula using sterile technique
Flattened catheter when blood flash
Advance catheter (not needle) into vein
Released tourniquet
Attached appropriate tubing
Documented I. V. start
S
19
NP
Comments
Date
Student Name
Care Plan
Assessment
Nursing Diagnosis
Outcomes
20
Interventions
21
Neuro/Head
Mental Status:
Memory intact:
Oriented (Yes/No) Person
Place
Time
Situation
Alert______ Drowsy
Lethargic
Comatose
Cooperative
Uncooperative_______
Combative___________Others________________________
Recent
Remote _______
Vision:
Acuity: Clear_____Diminished _____ Blind_____ Which Eye_________________________
Pupil size: Equal
Unequal
Which Eye____________________________________
Right: Pupil Response: Brisk
Sluggish
Absent ______
Left: Pupil Response: Brisk
Sluggish
Absent ______
Glasses: Yes
No
Contact lenses: Yes No
Eyes:
Moist
Dry
Sclera: White ___ Jaundiced ____
Color of conjunctiva: Pale
Pink
Jaundiced _____
Hearing:
Right: WNL
Left: WNL
Teeth:
Normal
Abnormal
Dentures: No
Upper
Swallowing problems: Yes
Describe___________________________________
Lower
Partial _____
No
Mouth
Mucous Membranes:
Describe____________
Moist
Chest
Respiratory:
Cardiovascular:
Impaired
Impaired
Deaf
Deaf
Hearing aids: Yes
Hearing aids: Yes
Dry
Color: Pale
No
No
Pink ____ Lesions _____
Rate
Depth: Shallow
Deep Abdominal
Diaphragmatic Irregular___
Breath sounds: Normal
Diminished
Equal on both sides _____
Lungs clear
Crackles: Fine ___ Coarse ___ Wheezes: Ins
Exp ___
Any 02: Yes
No
Via cannula Mask
Trach
ET___ Rate/% _O2 sat_
Deep breathing and coughing: Yes
No
Spirometer ______
Cough: Yes
No
Sputum: Yes
No
Quality
Color ___________
Chest tube: R ___ L ___ M ___ Suction ___ Gravity __ Drainage:________________
Cyanosis: No
Yes
Where
HR_____ B/P_____
Heart sounds: Strong
Weak
Regular
Irregular
Murmur _____
Pulses palpable: Pedal: L ___ R ___ Radial: L ___ R ___
Telemetry: Yes ___ No ___ Reading ___________________ JVD:Yes__No__
Other: ____________________________________________________________
GI
Nausea/Vomiting:
Yes
Appetite:
Good
N/G tube:
No
Yes
Patent
Suction: Intermittent
Continuous Output ______cc
Character and amount of drainage ___________________________________________
Abdomen:
Soft
Hard
Distended
Nondistended
Tender
Non-tender _____
Bowel sounds: Present
Absent
Hypoactive________ Hyperactive _______
Date of Last BM_________ Colostomy _____ Color
Consistency ___________
Continent _____ Incontinent_____
Height______Weight______ pounds/inches squared X 705 =______conclusion_______
BMI
Tubes
Torso
Skin:
No
Describe emesis____________________________________________
Poor
Intake of food: Diet______% of food
Fluids
cc
F.T. ___PEG ___ J. Tube ___
Rate _____ Type of Solution___Intake:__cc
J.P. ___ Hemovac ___
Describe Drainage_______________________________
Others______________________________________________________________
Moist
Dry
Pink
Pale
Jaundiced _____
Intact
Lesions, rashes, bruises
Describe___________________________
Wounds: Where______________Dressing dry and intact______Dressing Changed_____
Describe wound__________________________________________________________
Incision: Where______________________Staples ___ Steri-Stripe ___ Condition______
22
Extremities:
Urinary
GU:
Movement
Musculoskeletal:
Sleep/Rest Pattern
Turgor: Firm
Dehydrated
Fragile _____
Edema: Yes No Pitting
Trace
+1
+2
+3
+4 ___
Where_________________________________
I. V. Site: ___________________________
I.V. Fluid intake:___________________cc
Temperature: Cold
Cool
Warm
Hot
Color: Pink
Pale
Cyanotic
Mottled ______
Capillary Refill: Seconds to refill ______
Homan's sign: Positive
Negative _____SCD_____________TEDS_______________
Voiding: Continent______ Incontinent______ Foley: No
Yes
Patent___
Color/clarity
Amount of urine _______________
Mobility: Ambulatory
Up in Chair
Bedrest _____
Any abnormalities in ROM, Gait, Balance ____________________________________________
Equipment Used____________________________________ Handgrips equal ______________
Any difficulties: No
Yes
Explain ________________________________________
Cognitive/Perceptual Pattern
Pain:
Knowledge Level:
Overt signs: Yes
No
C/O Pain No
Yes
Location
__________________
Intensity: Scale (1-10)
Pain Medication
Results________________
Knows current medical problem and treatment regimen Yes
No ___
Self-Perception/Self-Concept Pattern
Patient appears:
Needs:
Calm
Anxious
Irritable
Withdrawn
Restless ____
Major stressors __________________________________________________________________
Grief/sadness
Frustration/anger
Fear/anxiety
Hopelessness____ Loneliness____
Role/Relationship Pattern
Language:
Speech Problems:
English
Other_______________________________________________________________
Yes
No
Describe______________________________________________________
Sexuality/Reproduction Pattern
Vaginal/Penile discharge, bleeding, lesions: Yes
No _____
Odor: Yes ___ No ___ Describe _________________________________________________
Coping/Stress Tolerance Pattern
Any signs of stress: Crying, wringing of hands, clenched fists: Yes
No _____
Any traumatic events in past year: Yes
No _____
Describe _______________________________________________________________________
Rate your handling of stress: Good
Average
Poor ____
Family support: Yes
No____
Family/Friends visiting: Yes___ No____
Value/Belief Pattern
Do you observe any implements of religion (Rosary, Bible, Religious Books) Yes
No ____
How can we help you maintain your spiritual strength: Prayer
Call Pastor/Clergy ______
Comments_______________________________________________
23
Successful IV starts
Student_______________________
Nursing 212
Rhonda Grey RN MSN
Sue Bouma RN BSN CRNI
1. Date
Gauge
Attempts
2. Date
Gauge
Attempts
3. Date
Gauge
Attempts
24
ALERT SHEET
What are you on alert today with this patient? (one problem, the one you think is most
important).
What are the important assessments to make?
What complications may occur?
What interventions will prevent these complications?
Were you right?
25
REFLECTION THROUGH JOURNAL WRITING
Reflection, or thinking about our experiences, is the key to learning. Reflection allows us to analyze our
experiences, make changes based on our mistakes, keep doing what is successful, and build upon or
modify past knowledge based on new knowledge. Reflection also allows us to make connections between
theoretical concepts and experiential learn.
The following are questions that the student will answer daily and hand into instructor at the end of each
clinical lab day. They must be type written.
1.
Describe a problem that that arose during the shift answering the following questions.
A.
Explain the circumstances of this problem including the steps that you took to
solve the problem.
B.
What knowledge or resources were required for you to solve the problem?
C.
What influenced your thinking about this problem?
D.
Was the problem solved?
F.
Review the steps of problem solving and then determine if the steps taken were in
priority order.
2.
Based on your portfolio, describe which competency you were to apply to the clinical
setting. Give an example.
3.
Describe your experience in relationship to thoughts, feelings and what you learned?
26
4.
W hat
concepts from the theory class were you able to apply to clinical practice? Describe
how you applied the concept.
27
Mental Health Clinical Experience
OBJECTIVES
At the completion of this experience, the student will be able to:
1.
2.
3.
4.
5.
Utilize active listening skills with client.
Apply therapeutic communication skills in initiating a client conversation
Collaborate with the health care team in developing, implementing or evaluating plan of
care.
Discuss the role of the registered nursing as a member of the mental health care team.
Assess the mental status and psycho social status of two clients.
Required Activities:
Pre Clinical
1.
Review module “Caring for the psychiatric patient” and answer the quiz questions.
2.
Answer the quiz questions for psychotropic medication.
3.
Review chapter on effective communication in your psychiatric nursing book.
Clinical
1.
2.
3.
Perform a mental status examination on two clients. Use the form provided identify the 3
nursing diagnoses as related to the assessment
Perform 2 process recordings. Use the form provided.
The student will locate the module on AIMS assessment module and answer the quiz
questions.
Perform two AIMS assessment for client on antipsychotic drugs.
Participate in at least one group therapy session and describe the following.
 What type of therapy session?
 What nonverbal cues were noted?
 Briefly describe the content discussed.
4.
5.
7.
Turn in reflection journal to instructor
Dress Code:
1.
2.
3.
4.
5.
Must wear your name badge.
May dress in casual clothes in good repair --in other words not torn or with holes.
No provocative clothing and no showing your waist line—midriff must be covered.
Only single stud earrings. No dangling earrings, bracelets or chains around neck.
No firearms, weapons, valuables, or drugs.
Mental Health Examination
The mental status examination is the recorded observation of the client’s appearance, symptoms, mood and
psychological function. This information can be elicited during the process of the first interview or during a time
that you are talking with the patient.
28
Student’s Name___________________________________Date____________________
Diagnosis of patient_______________________________________________________
Brief history of signs and symptoms that led to the diagnosis_______________________
________________________________________________________________________
List of medication (both medical and psychiatric drugs)___________________________
________________________________________________________________________
________________________________________________________________________
Appearance and behavior.
Well groomed_______Disheveled______________ Bizzare_________________
Hygiene: Normal__________Poor__________Others______________________
Affect: Bland____flat_____inappropriate_____depress_______
Anxious_____WNL____pressured______
Stream of Talk
WNL________fast_____slow__________flight of ideas________ coherent______
Concise______disconnected word salad______distractibility__________________
Others:_______________________________________
Emotional State:
Mood: Hostile_______,depressed________ Euphoric_________Vegetative________
GI symptoms: diarrhea, constipation, anorexia, weight loss_______________
Insomnia_____
Other_________________________________
Content of thought and fantasy
Concerns_______preoocupations_______topic of conversation__________________
Phobias_________obsessions_________difficulty concentrating__________________
Hallucinations___________________delusions____________grandiosity___________
Suicidal thoughts_______________________________________________________
Others_________________________________________________________________
29
Mental Status Examination page 2
Sensorium and Intellect:
Orientation: time______place______person__________situation_________
Memory Remote (use questions regarding date of birth or historical events)__________
Memory Recent (use questions regarding last 24 hours)___________________________
Retention and Recall: use number forward or backward and see how many they can recall. Educate them in regards
to a medication that they are on and then before you leave ask them a question regarding the
medication________________________________________________________________________
Intelligence: Knowledge consistent with education and background.________________________________
________________________________________________________________________________
Ability to abstract:
and a river.
Ask question regarding difference such as a child and a midget or similarities such as an ocean
Insight:
Understanding of symptoms___________
Denial of problem________________
Judgment:
Plans for the future
Motivation:
Does the client want therapy?______ How is the client participating in
care?_____________________________________________________
Rapport:
Was there any?______________Significant verbal and non-verbal cues________________
Nursing Diagnosis (require 3)
30
ABNORMAL INVOLUNTARY MOVEMENT SCALE
AIMS
Examination Procedure
Either before or after completing the examination procedure observes the patient unobtrusively,
at rest (e.g., in waiting room)
The chair to be used in this examination should be a hard, firm one without arms.
1.
Ask patient whether there is anything in his/her mouth (i.e. gum, candy, etc. ) and if there
is to remove it.
2.
Ask patient about the current condition of his/her teeth, Ask patient if he/she wears
dentures. Do teeth or dentures bother patient now?
3.
Ask patient whether he/she notices any movements in mouth, face, hands, or feet. If yes,
ask to describe and to what extent they currently bother patient or interfere with his/her
activities.
4.
Have patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor.
(Look at entire body for movements while in this position).
5.
Ask patient to sit with hands hanging unsupported. If male, between legs, if female and
wearing dress, hanging over knees. (Observe hand and other body areas.)
6.
Ask patient to open mouth. (Observe tongue at rest within mouth.) Do this twice.
7.
Ask patient to protrude the tongue (observe abnormalities of tongue movement.)
8.
Ask patient to tap thumb, with each finger, as rapidly as possible for 10-15 seconds;
separately with right hand, then with left hand. (Observe facial and leg movements.)
9.
Flex and extend patient’s left and right arms (one at a time). Note any rigidity
10.
Ask patient to stand up. (Observe profile. Observe all body areas again, hips included.)
11.
Ask patient to extend both arms outstretched in front with palms.
12.
Have patient walk a few paces turn and walk back to chair. (Observe hands and gait.) Do
this twice.
31
PROCESS RECORDING
Student’s Name_____________________________________
Diagnosis of Patient_________________________________
OBJECTIVE STATEMENT
Client says and does
Date_______________________________
Length of
Interaction__________________________
Student Thinks and Feels
SUBJECTIVE STATEMENT
Student says and does
PROCESS RECORDING
32
Assessment of Interaction
Student’s Name_____________________________________
Diagnosis of Patient_________________________________
OBJECTIVE STATEMENT
Client says and does
Date_______________________________
Length of
Interaction__________________________
Student Thinks and Feels
SUBJECTIVE STATEMENT
Student says and does
33
Assessment of Interaction