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Medical-Surgical I Nursing Clinical
NURS 1105: Wednesday & Thursday 6am-2pm
First Semester Fall 2008
Vicky O’Neil, FNP-BC
oneil@dixie.edu
Office: 358 Russell Taylor Health Sciences Building
Office Hours: Tuesday 1pm-4pm & Friday 9am-11am
Phone:
Office: 435-879-4808
Home: 435-635-9286
Cell: 435-229-0761
Ruth Ann Adams, BSN
Cell: 435-862-0434
Laura Thomas, BSN
XXXXXXXXXXXX,
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This syllabus is for information purposes only, is subject to change and is only a guideline for
the course. All changes will be provided to each student in writing and the student will be
accountable for all written change.
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COURSE DESCRIPTION
Clinical experience with focus on learning the nursing process & developing a nursing plan of care while
caring for the older adult. Corequisites: NURS 1100 & 1101.
REQUIRED TEXTS & MATERIALS
Carpenito-Moyet, L.J. (2008). Handbook of nursing diagnosis (12th ed.) Philadelphia: L.W.W.
Deglin, J. H. & Vallerand, A. H. (2006). Davis’s drug guide for nurses (10th ed). Philadelphia: F. A.
Davis.
Karch, A.M. (2009). 2009 Lippincott’s nursing drug guide 25th ed.) Philadelphia: L.W.W.
Linton, A.D. (2007). Introduction to medical-surgical nursing (4th ed.) Saunders Elsevier: U.S.A.
Pagana, K.D. & Pagana, T.J. (2006). Mosby’s diagnostic and laboratory test reference (8th ed.).
St. Louis: Mosby, Inc.
Perry, A.G, & Potter, P. A. (2006). Clinical nursing skills & techniques (6th ed). St Louis:
Mosby, Inc.
Stethoscope
Watch with a second hand
Penlight
GRADING CRITERIA
The clinical component of Medical-Surgical Nursing is graded as pass or fail. You must achieve at least 74%
to receive a passing grade. You may not request time off from clinical to work or leave clinical to work. An
unsatisfactory rating for any clinical day will be given if the instructor deems the student unprepared (i.e. without
assignments completed or not dressed in school uniform) to attend clinical that day. Missing clinical for work,
leaving clinical for work, two unsatisfactory days, or a grade less than 74% will result in failure of the clinical
component & dismissal from the nursing program. All written assignments must be completed and submitted on
or before the date that they are due at 0600. Late assignments will receive a 10% deduction in score for each day
late up to 4 days beyond the due date. Late assignments will not be accepted after 4 days beyond the due date.
CLINICAL RUBRIK
Critical Thinking
250 Points
Technical Skills
150 Points
Therapeutic Communications
100 Points
Nursing Process
250 Points
Time Management & Organization
100 Points
Professionalism
50 Points
Leadership & Management
50 Points
Caring
50 Points
1000 Total Points
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PURPOSE OF THE CLINICAL EXPERIENCE
The purpose of the clinical experience is to provide the student with the opportunity to apply the nursing
process and learned nursing skills in the simulation laboratory and clinical setting. This allows the student to
prepare for “hands-on” nursing practice in a supervised setting. Opportunities to address the areas mentioned in the
student evaluation found in this syllabus are provided during each clinical day. The student is requested to study the
Student Clinical Evaluation Form in preparation for the clinical experience. The opportunity to apply the nursing
process and learned nursing skills to direct patient care is an important responsibility of each student. It is important
to treat each patient with respect and dignity. Students must act as guests in the facility by treating the facility and
the facility staff with respect. We are grateful for the opportunity to train in the clinical setting. It is an enriched
environment for learning and applying both the nursing process and nursing skills.
COURSE OBJECTIVES
1. Demonstrate proficiency in the role of the practical nurse by showing competency in the following areas:
Drug Calculations Exam, Pre-Clinical Skills Testing, and assignments.
2. Demonstrate critical thinking in client care or simulation through completion of critical thinking
assignments; creating care plans/concept maps; identifying evidence-based practice and implementing it into
nursing practice, and discussing clinical problems during the clinical setting and/or post-conference.
3. Apply technical skills through safe practice by reviewing ATI Skills Modules; attendance at all assigned
Skill Labs; practicing the skills in the lab with a partner every month; performing skills while being observed
by instructors and nurses in the clinical setting; and passing the practicum using the Lab Practicum Rubric.
4. Demonstrate therapeutic communication skills by navigating through the client’s chart; receiving report from
the the preceding shift/giving report to other nurses; communicating in a timely manner abnormal client
findings to the instructor and nurse on duty; charting under the supervision of the instructor or nurse; and
using assertive communication skills with clients and health team members.
5. Demonstrate leadership/management by identifying the practical nurse and other team members scope of
practice, facilitating post-conference debriefing, and utilizing delegation skills appropriately.
6. Demonstrate time management/organization by being punctual for clinical schedules; planning ahead by
completing assignments on time; creating and obtaining weekly goals; and prioritizing care for clients with
complex needs.
7. Demonstrate professional behavior by following the ANA code of ethical behavior and the Dixie State
College Nursing Student Handbook; functioning within the practical nurse scope of practice; and
implementing HIPPA provisions.
8. Demonstrate caring by establishing and maintaining relationships of trust with clients, colleagues, and
instructors in the clinical setting; promoting individualized care by soliciting the client’s input, especially in
relation to the client’s ethnicity and culture; and while caring for the client ensure they are treated in a
humane and dignified manner.
DRUG CALCULATIONS
You must take a drug calculations test & pass with a score of 100% to participate in the clinical
component. You will be required to study assigned chapters in the Medical Dosage & Calculations books then take
a short quiz. After completing all assigned studies & quizzes you may take the calculations test. If you do not score
100% you will be required to take another test. If you do not pass the 2nd test you will be required to meet with me
for remedial help. You will be given the opportunity to take a 3rd calculations test. If on your 3rd attempt to pass
the calculations exam you do not pass with a score of 100% you will not be allowed to participate in the
clinical component, resulting in withdrawal from the nursing program.
PRE-CLINICAL SKILLS CHECK OFF
You must pass off on the following skills with a score of 74% or greater to attend clinical.
1. Physical assessment of an adult client
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2. Calculate dosage and give oral medication. Verbalize the 6 rights.
3. Calculate dosage, prepare injection from an ampule & vial in one syringe, identify the ventrogluteal site, then
administer an IM injection via Z-Track.
4. Calculate dosage, mix regular & NPH insulin in one syringe, identify appropriate sites for subq injections,
then administer a subq injection.
5. Verbalize verification of placement of an enteral tube and medication administration through it.
6. Demonstrate use of different oxygen tubing and portable oxygen tank.
7. Demonstrate tracheostomy care to include airway suctioning.
8. Insert a foley catheter.
Proper documentation of a disability is required in order to receive services or accommodations. Any student
eligible for & requesting reasonable academic accommodations due to a disability must provide a letter of
accommodation to their professor from the Disability Resource Center within the first two weeks of the beginning of
classes. Please contact the Center on the main campus to follow through with the documentation process. We are
located in the Student Services Center Room #201, or you may call for an appointment and further information
regarding the Americans with Disabilities Act (ADA) at 652-7516.
ACADEMIC INTEGRITY/STUDENT CONDUCT
“A fundamental quality of all successful nurses is integrity and a genuine concern for the well being of the
patient. Quality professional patient care requires a relationship built on trust, trust requires honesty, and honesty is
the foundation of integrity.”
Academic Integrity is expected of students and faculty at Dixie State College. Students are expected to abide
by the Dixie State College of Utah (DSC) student code available at http://www.dixie.edu/humanres/polstu.html.
Dixie State College takes a very serious view of violations of academic integrity. As members of the academic
community, the College’s administration, faculty, staff, and students are dedicated to promoting an atmosphere of
honesty and are committed to maintaining the academic integrity essential to the educational process. Inherent in
this commitment is the belief that academic dishonesty in all forms violates the principles of integrity and impedes
learning.
Students in DSC Nursing Programs have a responsibility to the public and to the nursing profession; thus, it
reserves the privilege of retaining only those students who, in the judgment of the faculty, demonstrate high
academic standards. These academic standards include honesty, accountability, and responsibility for one’s own
work. Academic dishonesty is an unacceptable mode of conduct and will not be tolerated in any form. Academic
dishonesty includes, but is not limited to, plagiarism, cheating, collusion, falsification, copying another student’s
work, and soliciting unauthorized information about an exam. Students who know about any form of cheating or
academic dishonesty and do not report it to appropriate individuals are equally guilty of academic dishonesty and
may face the same consequences. Students who violate the student code of conduct or rules of academic integrity
may be subject to dismissal from DSC Nursing Programs and the college according to college policy.
REBELMAIL
Important class & college information will be sent to your Rebelmail email account. This information includes your
DSC bill, financial aid/scholarship notices, notification of dropped classes, reminders of important dates & events, &
other information critical to your success in this class & at DSC. All DSC students are automatically assigned a
Rebelmail email account. If you don’t know your user name & password, go to www.dixie.edu & select
“Rebelmail,” for complete instructions. You will be held responsible for information sent to your Rebelmail email,
so please check it often.
ATTENDANCE & TARDINESS POLICY
Attendance is essential because of the demanding nature of the nursing program. The instructors will adhere
to the guidelines regarding attendance and tardiness that are described in the Nursing Student Handbook. Excessive
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absences or excessive tardiness may result in a grade reduction or dismissal from the program. It is to your
advantage to notify the instructor in advance if you must miss a class. Missing clinical for work or leaving clinical
for work will result in failure of the clinical component.
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Clinical Scavenger Hunt
Complete the following: You may work in groups of 2 or 3. You may start anywhere on the units. Please
stagger yourselves and do not all start in one location. Behave professionally, working quietly and respectfully, and
provide for patient privacy at all times.
Patient Care Items:
1. Where are the clean linens located? _____________________________________________
2. Where is the dirty utility room?_________________________________________________
3. Where are the Foley catheter kits stored?_________________________________________
4. Where are the personal care items stored (lotion, deodorant, toothpaste, shampoo, bath soap, baby powder,
Kleenex)?______________________________________________________
5. Where are urinals & bedpans stored? ___________________________________________
6. Where are the gradients?______________________________________________________
7. Where are dressing change supplies?____________________________________________
Patient Information:
1. Where in the chart are the pt’s medical diagnoses listed?______________________________
2. Where can you find the pt’s code status? __________________________________________
3. Where are the pt’s allergies listed? _______________________________________________
4. What is the abbreviation for a person without allergies? ______________________________
5. Where are the pt’s nursing diagnoses listed? _______________________________________
6. What kind of documentation system is used? _______________________________________
Resources:
1. Where are the provider’s phone numbers? ________________________________________
2. Where is the facility’s policy and procedure manual located?__________________________
3. Where are the medication reference books? _______________________________________
4. What other reference books are available on the units?_______________________________
__________________________________________________________________________
5. Which pharmacy does the facility use?___________________________________________
Ancillary Services:
1. Where is gait training done? ____________________________________________________
2. Where can a patient get a haircut? _______________________________________________
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3. Where are social activities held? ________________________________________________
4. Who organizes the social activities? ______________________________________________
5. Where are meals served?_______________________________________________________
6. How can you order special food or a diet for a patient? _______________________________
7. Where can you find assistive devices for your patient? _______________________________
Emergencies:
1. Where are the fire alarms located?_______________________________________________
__________________________________________________________________________
2. Where are the fire extinguishers located on each unit?_______________________________
__________________________________________________________________________
3. Where are the portable oxygen tanks stored?_______________________________________
4. Where are the emergency evacuation maps posted?__________________________________
___________________________________________________________________________
Professionalism:
1. What is the starting salary for an LPN in this facility? _______________________________
2. Who does the scheduling? _____________________________________________________
3. Does the facility provide malpractice insurance for the nurses? ________________________
4. Who is the Director of Nursing (DON)? __________________________________________
5. What is the DON’s highest educational degree? _____________________________________
6. Does the facility provide continuing educational opportunities for the nurses? ____________
When you have completed the scavenger hunt, return the completed copy to your instructor.
Dixie State College
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Practical Nursing Program
Clinical Evaluation Tool
Student___________________________________ Absence(s)_________ Late(s)_______
Instructor_______________________________ Semester__________________________
Medical/Surgical: Date completed_________________ Rating ( ) S
( ) NI
( )U
Evaluation Key
The following outcomes serve as guidelines for student performance in the clinical setting. Evaluation of these
outcomes is a process involving both faculty and student. Evaluation provides each student with a written progress
report and identifies any areas requiring change and/or improvement. Ongoing formative evaluation is part of the
teaching learning process and occurs at regular intervals at the discretion of the clinical faculty. Clinical
performance is graded with S, NI, U and NA as described below.
S – Satisfactory
Clinical behavior and/or work meet all aspects of the performance described in the outcome.
NI –Needs Improvement
Clinical behavior and/or work is safe but does not meet all aspects of the performance described in the outcome, or
performance is inconsistent. NI is given, when appropriate, during midterm evaluation. The student is then given an
outline of specific criteria to meet in order to obtain a satisfactory grade. Any NI given at midterm must be
converted to an S at semester end or it will result in a final U.
U –Unsatisfactory
Clinical behavior and/or work is either unsafe, inconsistent, or inadequate in meeting all aspects of the performance
described in the outcome. Any U given at midterm must be converted to an S at semester end or the student cannot
progress. The student is given an outline of specific criteria to meet in order to obtain a satisfactory grade. Any U
grade at semester end will result in a fail for the clinical portion of the course and the student will not be allowed to
continue in the nursing program.
NA – not applicable
May be given for an outcome which is either not observed or not applicable; however, faculty and student should
attempt to obtain the experience described in each outcome.
In summary, in order to successfully complete the clinical component of any nursing course, all outcomes must be
evaluated as satisfactory at semester end.
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OUTCOME PERFORMANCE CRITERIA
Midterm
S
NI
U
Final
S
NI
U
1. Critical Thinking
a. Assumes responsibility for own learning
b. Demonstrates application of classroom concepts to clinical practice
c. Uses basic problem solving skills to identify problems and seeks assistance with
problem solving
d. Identifies and utilizes various sources for answering questions
e. Shows initiative by reading and seeking learning opportunities (other than what is
require) to expand knowledge
f. Understands rationale behind patient care guidelines and procedures
2. Technical Skills
a. Uses basic equipment to perform procedures safely
b. Identifies and follows established standards when performing basic procedures
c. Observes all OSHA standards, rules, and regulations
d. Able to perform all assigned skills with accuracy
3. Therapeutic Communication
a. Records/documents client information, care, and evaluation of care in a clear,
concise manner, both verbally and written
b. Assists the RN in the teaching of information to clients and families as needed and
information is consistent with the nurse’s knowledge
c. Assists the RN to evaluate the effectiveness of client’s learning
d. Gives/receives nursing change of shift report in an effective manner
e. Begins using basic communication skills in interacting with clients/colleagues
f. Participates in resolution of issues related to team conflict in assertive and
responsible ways
g. With assistance, communicates assertively and responsibly with distressed,
aggressive, or unpopular clients/colleagues
h. Receives feedback/criticism from evaluations in an assertive, positive manner
i. With assistance, assertively reports breech of nursing care standards using the
appropriate chain of command
j. Identifies barriers to communication: physical, developmental, psychological,
emotional, cultural, and language
4. Leadership/Management
a. Under direction of a registered nurse, promotes goals of workplace as to costs,
safety, and quality client care
b. Works as an effective member of the health care team
c. Appropriately identifies and supervises basic tasks to unlicensed health care
personnel, recognizing their personal and professional limitations
d. Demonstrates accountability for supervision of nursing care delegated to unlicensed
health care personnel
5. Time Management/Organization
a. Able to manage personal time/actions to work effectively in the care setting
b. Plans and implements basic care for a group of clients
c. Demonstrates competence by meeting clinical schedules without being late or
absent
d. Is prepared with assignments as outlined
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OUTCOME PERFORMANCE CRITERIA
S
NI
U
S
NI
U
6. Professional Behavior
a. Follows ANA code of ethical behavior, while developing an awareness of
personal values/standards, and client values/standards
b. Understands the PN’s full scope of legal responsibility and accountability and uses
legal safeguards in clinical practice
c. With guidance, identifies potential liabilities in individual practice and develops
prevention strategies
d. Functions within scope of practice of the licensed practical nurse in various health
care settings
e. Maintains client confidentiality
f. Identifies individual strengths and weaknesses and seeks improvement as
appropriate
g. Displays initiative in participating in educational opportunities
h. Demonstrates support of professional activities
i. Acts to promote nursing and health care in general
j. Participates effectively in formal group discussions such as post-conferences
k. Promotes personal wellness to enhance caregiving abilities
7. Caring
a. Establishes and maintains relationships of trust with clients and colleagues
b. Uses “caring behaviors” to convey respect and acceptance, and to promote health,
self-care, and affirm individual worth
c. Promotes values and choices of the client
d. Advocates for the client
e. Promotes human dignity and diversity
f. Demonstrates interest in clients and client care by giving individualized, quality,
basic nursing care
8. Utilizes Nursing Process
a. Performs ongoing basic physical, emotional, spiritual, socio-cultural, and
nutritional data collection of clients across the lifespan as appropriate for scope
of practice
b. Establishes a data base by utilizing the nursing process
c. Follows appropriate basic NANDA nursing diagnosis
d. Soliciting client input, determines appropriate client outcomes
e. With the client, develops a basic plan of nursing care to meet client outcomes
f. Adjusts the plan of care to meet the client’s changing holistic needs
g. Identifies and facilitates interdisciplinary interventions to achieve basic outcomes
h. Establishes priorities for basic nursing care and intervenes appropriately with
assistance
i. Consistently performs basic nursing care of clients across the lifespan safely seeks
assistance when indicated
j. With client input, determines effectiveness of nursing interventions
k. Appropriately modifies client outcomes as indicated by client response
l. Utilizes all steps of the nursing process in the safe administration of medications
within scope of practice
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Midterm Evaluation Comments
This
Signatures:
Student____________________________________________________________________Date____________________
Faculty____________________________________________________________________Date____________________
Final Evaluation Comments
Evaluation has been shared between faculty and student. Criteria detailing any U grade has been explained and the student has
been advised regarding program status.
Student signature: _____________________________________________ Date: ________________________
Faculty signature: _____________________________________________ Date: __________________ _____
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Patient Profile Database
Student Name
ADMISSION INFORMATION
Date of Care:
Sex
Pt. Initials
Reason for Admission (face sheet)
Age
Date of Admission
Cultural Considerations
Surgical Procedures (H&P)
Past Medical History: Medical Diagnoses
ADVANCE DIRECTIVES (front of chart)
Living Will:
YES
NO
Healthcare POA:
YES
NO
POLST:
YES
NO
PERTINENT LABORATORY DATA
Test
Norms
Admit
Current
Comments
PERTINENT DIAGNOSTIC TESTS
TREATMENTS
ADL’s
Feeding: independent_______
needs assistance_______
Dressing: independent_______
needs assistance______
Toileting: independent______
needs assistance_______
Hygiene: independent_______
needs assistance_______
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Patient Profile Database
ALLERGIES:
Medication
Reason pt is on the med.
Nursing Considerations &
Pt Teaching
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Physical Assessment
General Survey:
Pain Assessment:
P__________________Q____________________R____________________S_________________T_______________
BP:
T:
P:
R:
O2 Sat:
HT:
WT:
BMI:
Neuro:
Alert / Lethargic / Stuperous / Comatose
Behavior: appropriate / inappropriate
Visual or Hearing deficit________________
Oriented X person / place / time / event
Hallucinations / Delusions / Agitated
Weakness: Y / N ______________
P E R R L: Y / N
Calm / Withdrawn / Converses easily
Paralysis: Y / N _______________
OD: Irregular shape / size________mm
Hostile / Paranoid / Anxious
Facial symmetry: Y / N _________
Affect: Normal / flat / animated
Speech: Clear
Reacts briskly / sluggishly / None
OS: Irregular shape / size________mm
S.T. memory intact: Y / N
Reacts briskly / sluggishly / None
L.T. memory intact: Y / N
Slurred
Unintelligible
Aphasia
Insomnia: Y / N
Notes:
Cardiovascular:
PMI: visible / palpable / ∅
Location___________ICS
Edema: None / 1+ / 2+ / 3+ / 4+
Location:_______________________________
Color of skin
Rhythm: Regular / Irregular
Trunk: pink / pale / mottled / purple / cyanotic
S1 S2: Clear / distant Extra heart sounds: Y / N
RLL: pink / pale / mottled / purple / cyanotic / brown / leathery / scaly
Cap refill: <3 seconds or _________seconds
LLL: pink / pale / mottled / purple / cyanotic / brown / leathery / scaly
Mastectomy: Right / Left
Pulses:
AV fistula: Right / Left
R Radial: doppler / weak / moderate / strong
R Dorsalis Pedis: Doppler / weak / moderate / strong
L Radial: doppler / weak / moderate / strong
L Dorsalis Pedis:: Doppler / weak / moderate / strong
Notes:
Respiratory:
Oxygen use: flow________L mode_________________
Chest expansion: symmetrical / non-symmetrical
Cough: effective / ineffective / productive / non-productive
Respiratory effort:
Resting: unlabored / mildy labored / labored / acute distress
Sputum: color_____________________ amount___________________
Cyanosis: none / circumoral / peripheral
With exertion: unlabored / mildy / labored / acute distress
C/O: SOB / Orthopnea / Paroxysmal nocturnal dyspnea
Breath Sounds:
LUL: I__________ E __________
RUL: I__________ E __________
LLL: I__________ E __________
RLL: I__________ E __________
RML: I__________ E __________
C = Clear
D = Diminished
R = Rales
Rh = Rhonci
W = Wheezes
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Physical Assessment
Gastrointestinal:
Diet____________________________
% eaten: < 25% / 25-50% / 50-75% / > 75%
NGT/GT feeding intake___________cc/hour
Nutritional Risk Assessment Score: ______________________
NGT/GT feeding residual___________cc
Condition of mouth__________________________________
NGT/GT/PO water intake___________cc/24 hours
Abdomen: round / flat / soft / firm / distended / tender vs non-tender to light palpation
Bowel sounds: 1=RLQ/ 2=RUQ/ 3=LUQ/ 4=LLQ (Circle appropriate)
normoactive_1_/_2_/_3_/_4_
hypoactive_1_/_2_/_3_/_4_
Date of last BM____________________
hyperactive_1_/_2_/_3_/_4_
Colostomy / ileostomy output during your shift ____________cc
Stoma color______________________
Notes:
Genitourinary:
Incontinence: always / sometimes
Vaginal/Penile Drainage_______
Void: always / sometimes
Perineal Rash_______
Foley_______
Ileostomy_______
Urinary: Frequency _______ Urgency_______ Dysuria_______
Characteristics of Urine: hematuria / tea-colored / amber yellow / pale yellow / clear / cloudy / mucous / sediment
Notes:
Musculoskeletal:
Muscle Strength 0/5: RUE_______ LUE_______ RLE_______ LLE_______
Falls Risk Assessment Score_________________
Amputations: RUE________LUE________RLE________LLE_________
ROM: Full = F, Decreased = D, Contractures: RUE_________LUE_________RLE_________LLE_________
Joint tenderness / redness / swelling_______________ Where______________________________________________________
Ability to walk: independent_______ uses walker_______ non-ambulatory______ Transfer: one person______ two person______ needs lift______
Uses electric wheelchair_______ Self propels wheelchair_______ Must be pushed in wheelchair_______
Notes:
Integumentary:
Tissue Turgor: normal / tenting
Pressure Ulcer Risk Assessment Score___________________________________________________
Skin: intact / ecchymoses / warm / cool / dry / moist / oily / scaly / peeling / dandruff
Incisions___________________________________________________Drains__________________________________________________________
Dressings__________________________________________________Wounds/Lesions__________________________________________________
Notes:
Psycho-Social Development: (circle which component applies)
Level for chronological age________________________________________vs________________________________________________
(According to Erikson)
Objective:
________________________________________________
Subjective:
____________________________________________
________________________________________________
____________________________________________
Personal Profile:
History of: Tobacco / Alcohol / Drug Abuse______________________________
Marital Status: Single / Divorced / Widow / Widower
Occupation___________________________________________
Who do they/did they live with?_______________________________________
Coping Mechanisms:________________________________________Support system____________________________________________________
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CONCEPT MAP RUBRIK
Pathophysiology
Medical/Surgical Treatment Options
PMH
Key Assessments
Medications
Subjective Data (ADL, ROS, & Pain)
Objective Data (Physical Assessment, Medical Diagnosis, Labs, Meds)
Analyze & categorize data
By body system list all major problems you note
Assign nursing diagnosis & state in correct format
Prioritize all the nursing diagnoses
Take the top 2 nursing diagnoses for the concept map
List goals/outcomes
List each nursing intervention followed by objective findings
Evaluate the patient’s overall progress towards goals
Draw the final concept map
For each diagnosis list all objective data noted
Findings from physical assessment
Medical diagnosis
Any diagnostic test results & Medications
List all subjective data (there will be no subjective data for at risk dx)
Add key assessment to the middle box
Analyze the relationship between the two diagnoses
7.5
2.5
5
5
10
7.5
7.5
10
7.5
5
7.5
10
2.5
10
2.5
Total Points_____________
COMMENTS
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Pathophysiology
Medical/Surgical Diagnosis:
Describe the Pathophysiology:
Etiology
Etiology for my pt
Clinical
Manifestations
Clinical manifestations
exhibited by my pt
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By body system list all major problems you note from your assessment (PMH, ADL, ROS, pain, physical assessment, medical diagnoses,
medications & diagnostic tests)
Assign & prioritize nursing diagnoses (State in correct format. __________ RT __________ AEB __________)
1.
2.
3.
4.
5.
6.
7.
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Nursing Diagnosis #1
Goal/Objectives:
Nursing Interventions:
1.
Objective/Subjective Findings/Responses
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
7.
7.
8.
8.
9.
9.
10.
10.
11.
11.
Summary/overall impression of the pt’s progress towards goals: Pt is or is not progressing towards goal AEB…
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Nursing Diagnosis #2
Goal/Objectives:
Nursing Interventions:
1.
Objective/Subjective Findings/Responses
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
7.
7.
8.
8.
9.
9.
10.
10.
11.
11.
Summary/overall impression of the pt’s progress towards goals: Pt is or is not progressing towards goal AEB…
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Nursing Diagnosis #1
Primary Medical Diagnosis:
Nursing Diagnosis #2
Co-Morbidities:
Objective:
Objective:
Key Assessments:
Subjective:
Subjective:
Analyze the relationship between the top two nursing diagnoses
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