Nursing 2104—Medical Surgical Nursing II
Course Calendar—Fall 2014
Monday
August 18
Tuesday
August 19
0830-1500
GI 55-60 & 63
0830-1500
GI Simulation until Noon
Test #1 Ch. 55-60 & 63
Class 1230-1500
----------------------Liver 61-62
August 25
August 26
Wednesday
August 20
Thursday
August 21
Friday
August 22
0830-1220
Cheria Lindsey, RN, BSN
School Screenings
0830-1130
*2 dif. GI ATI Practice Test due
August 27
August 28
August 29
0830-1500
Clinical
Clinical
DM/ Endocrine
Ch. 64- 67
*Pick 2 Nutrition ATI Tests- due
September 1
Labor Day
September 2
0830-1500
September 3
September 4
0830-1220
September 5
Test # 2 Ch. 61-62 & 64-67
------------------------
DM/ Endocrine Cont.
Burns/Skin ch. 26 & 28
* Endocrine ATI Practice Test Due
September 8
Clinical
September 9
Clinical
September 10
September 11
0830-1220
September 12
Anxiety, Mood Disorders, &
Schizophrenia
ATI
*Questions TBA
September 15
Clinical
September 16
Clinical
September 17
September 18
0830-1220
Test # 3 Ch. 26 & 28 and ATI
chapters on Anxiety, Mood D/O, &
Schizophrenia
Immune Function ch. 19, 20
*ATI Mental Health Practice Test Due
September 19
Nursing 2104—Medical Surgical Nursing II
Course Calendar—Fall 2014
September 22
Clinical
September 23
Clinical
September 24
September 25
September 26
0830-1220
Rheumatic & Allergic D/O, HIV ch.
21-22, & 25
*Immune ATI Practice ID 5554142 Test
Due
September 29
Clinical
September 30
Clinical
October 1
October 2
October 3
0830-1220
Test #4 Ch. 19-22 & 25
*Immune ATI Practice ID 5689835 Test
Due
October 6
Clinical
October 7
Clinical
October 8
October 9
0830-1220
Comprehensive Final Exam
Orientation for Pediatric Nursing
October 10
NORTH ARKANSAS COLLEGE
Department of Nursing
Nursing 2104
Course Title:
Medical Surgical Nursing II
Instructors:
Jennifer James, RN; MSN, CNE
Room: A100
870-391-3528
jjames@northark.edu
FAX: 870-391-3354
Cell: 501-517-2767
*I prefer to be emailed with any questions or comments. If you need immediate assistance, you
may call my cell phone, but otherwise please use the preferred method of email.
NURS 2104 Medical-Surgical Nursing II (4) 4L, 12LL (8-week course)
Medical-Surgical Nursing II is an 8 week course that continues the study of adult medical-surgical patients. The
Student Learning Outcomes are expanded upon with an emphasis on patient-centered care, cultural diversity,
communication, teamwork, and clinical reasoning. Safety concepts are emphasized to reduce preventable errors
and promote positive patient outcomes. Theory and clinical experiences are related to the course content. Prerequisite:
Credit and Time Allotment:
4 semester credit hours
4 Hours of theory/week Thursday 8:30-12:30
12 hours of clinical/week
Audience for course:
Second level nursing, first semester
Course Progression:
Upon successful completion of NUR the student may progress to
Pediatric Nursing NURS 2114
Course Outcomes:
Upon successful completion of this course, the student should be able to:
Human Flourishing
1. Demonstrate patient centered care while applying the nursing process, (measured by
exam, written assignments, and clinical practice).
2. Utilize therapeutic communication skills to establish and maintain therapeutic nurse patient
relationships with patients, families, significant others, small groups of patients, and
colleagues, (measured by exam, written assignments, and clinical practice).
3. Practice culturally competent care to meet the needs of patients and significant support
person(s) respecting each persons’ cultural diversity, (measured by exam, written
assignments, and clinical practice).
Nursing Judgment
4.
Demonstrate evidence based practice involving accurate assessment and safe
performance of nursing skills, (measured by exam, written assignments, and clinical
practice).
5.
Collaborate with the patient, significant support person(s), and members of the
healthcare team to achieve positive patient outcomes, (measured by exam, written
assignments, and clinical practice).
6.
Appraise safety and quality control issues both in the acute setting as well as the
community setting, (measured by clinical
assignments and post conference participation).
7.
Examine resources available to patients that promote health when planning and
implementing evidence based practice, (measured by clinical assignments, and
post conference participation).
8.
Interpret the professional nurses’ role and responsibilities in the delegation of care
to assistive personnel and its impact on teamwork, (measured by clinical
assignments, and post conference participation).
Spirit of Inquiry
9.
Utilize clinical reasoning skills in planning, implementing, and evaluating holistic
nursing care, (measured by exam, written assignments, and clinical practice).
10.
Apply clinical decision making skills when managing care of patients, families, and
communities, (measured by clinical practice and post conference participation).
Professional Identity
11.
Demonstrate professional behavior by being responsible and accountable for the
ethical and legal aspects of nursing care provided to patients, families, and
communities, (measured by exam, written assignments, and clinical practice).
12.
Utilize technology (informatics) to support positive patient outcomes, (measured by
clinical practice).
13.
Complete a patient centered teaching plan to assist patients and families regarding
their plan of care, medical diagnosis, medications, and treatment
regimen,(measured by classroom & clinical assignments).
Required Textbooks:
Ignatavivius, M. and Workman, L. (2013) Medical-Surgical Nursing: Patient-Centered
Collaborative Care, 7 th ed., St. Louis, MO: Elsevier-Saunders.
Evolve Elsevier Adaptive Learning and Quizzes.
ATI
Major Teaching-Learning Activities:
Teacher: Lecture
Discussion
Demonstrations
Audiovisual presentations
Classroom assessment techniques
On line assignments
Learner:
Discussion
Small group conferences
Role playing
Independent study guides
Nursing skills laboratory practice
Computer assisted instruction
Grading:
Grading:
The final course grade is determined as follows:
Unit Examination .......................... 70%
Comprehensive Final ................... 20%
Classroom Assignments* ............. 10%
Clinical Component is Pass/Fail
*The classroom assignments grade is added ONLY after the student has achieved a 79% or
above on all examinations.
If a student has less than a passing average (79%) on unit tests and the final, the student will not
progress in the program. Please meet with the instructor if you do not achieve a 79% or above
following the second examination.
Students must pass the clinical component of the course in order to progress in the program. If
the student fails the clinical component with an unsatisfactory summative evaluation, the theory
grade drops to a "D" and the student cannot progress. See Clinical Section of syllabus.
Classroom Assignments
Refer to course calendar for due dates of assignments.
NCLEX style Questions and ATI Practice Exams 10%
ATI Practice Exams must be completed by 0830 on the date according to the course
calendar. A score of 90% or better is required on all ATI Practice Exams. There is no limit
on the number of attempts, but the exam must be completed prior to the due date. If you do
not make 90% or better, then you will receive a zero for that assignment. Please read your
rationales closely to help you improve your test taking skills.
Grading Scale:
A
90.5-100
B
83.5-90.4
C
78.5-83.4
D
69-78.4
F
<69
Grades will be rounded to the nearest whole number. Example: 78.45 will round to a 78% and a
78.58 will round to a 79%.
Attendance:
Students are expected to attend all class meetings. Missing more than 15% of scheduled
class meetings (six class hours in a traditional 3 credit lecture course) constitutes
excessive absence. In online classes, a student’s failure to participate for a period greater
than two weeks constitutes excessive absence. Instructors in online courses will monitor
attendance based on participation in the class as evidenced by turning in assignments,
participation in discussion boards, e-mail, or other formal contact.
Students must see the instructor and explain tardiness. Only in extreme circumstances will
tardiness be excused.
Clinical days scheduled “on campus” are designed for clinical experiences and guidelines for
clinical absences are applicable.
Academic Assessment:
Various methods are used to evaluate student academic achievement. These methods include,
but are not limited to:
1.
written assignments
2.
clinical skills lab and simulation
3.
ATI computerized exams
Make-Up Exams:
1.
All exams should be taken at the scheduled time.
2.
The student MUST notify the instructor prior to the exam if the student is unable to take
the exam at the scheduled time. A missed examination is considered a class absence.
3.
Arrangements must be made by the student with the instructor on return to classes.
4.
Student may make-up one test only per semester at the instructor's discretion.
5.
Failure to comply with the stated requirements omits the privilege of taking a make-up test.
A zero will be given for the test not taken.
6.
An alternative exam may be administered.
Course Requirements:
1.
The student is expected to attend class, laboratory sessions, and clinical.
2.
The student is expected to be prepared for classroom, laboratory activities, and clinical.
3.
The student is expected to complete all written assignments as directed by the instructor.
4.
The student is required to complete independent study activities.
5.
The student is expected to meet all course outcomes.
6.
The student is to write examinations on designated dates.
Conferences:
Instructors are available for conferences during posted office hours and/or by appointment.
The student or the instructor(s) may initiate conferences concerning the student's performance or
status in the classroom or clinical component of the course as needed.
Academic Dishonesty:
North Arkansas College's commitment to academic achievement is supported by a strict but fair
policy to protect academic integrity. This policy regards academic fraud and dishonesty as
disciplinary offenses requiring disciplinary actions. Any student who engages in such offenses
(as here defined), will be subject to one or more courses of action as determined by the
instructor, and in some cases the Division Chairperson or Program Director, the Vice President of
Instruction, and Institutional Standards and Appeals Committee as well.
Academic fraud and dishonesty are defined as follows:
Cheating:
Intentionally using or attempting to use unauthorized materials, information, or
study aids in any academic exercise.
Test
Tampering: Intentionally gaining access to restricted test booklets, banks, questions, or
answers before a test is given; or tampering with questions or answers after a test
is taken.
Plagiarism:
Intentionally or knowingly representing the words and ideas of another as one's own
in any academic exercise.
Facilitating
Academic
Dishonesty: Intentionally or knowingly helping or attempting to help another commit an act of
academic dishonesty.
Clinical Policies and Evaluation:
S = Satisfactory
Students meet minimum requirements for the course clinical outcomes.
N = Needs Improvement
Students did not meet minimum requirements for 1 or more core competency for that
program outcome. If an N is received then the student and instructor are expected to:
1. Discuss the issue during the clinical rotation.
2. The instructor will document the discussion on the clinical formative evaluation tool.
3. The instructor will fill out the clinical warning form.
4. The student will formulate a remediation plan to be presented to the clinical instructor
and course coordinator. (If applicable).
5. If after remediation, the student receives another NI, the process will be repeated once
more.
If the student receives 3 N’s in the same program outcome category, such as Human Flourishing,
on separate occasions during a course clinical rotation then they will receive a U for that clinical
rotation and will be dismissed from the program.
U = Unsatisfactory
Student did not demonstrate essential skills for patient safety, professional behavior etc. as
stated in the RN Handbook. If the student participates in any of the reasons for dismissal as
listed in the RN Handbook they will receive a U on the clinical formative evaluation tool.
Students are allowed 3 attempts to pass a clinical skill in the simulation lab. If the student is not
successful, a remediation plan will be discussed and implemented between the instructor and the
student. If the student does not pass the skill on the 3 rd attempt, they will fail that skill and not be
eligible to continue in the nursing program.
Clinical Experience:
Concurrent clinical experience is provided in appropriate clinical settings. Specific hours and
locations for clinical assignment will be announced in class.
The type of clinical assignments may vary by institution and specific unit because of variations in
hospital policy and procedures and patient populations. The level of clinical assignment will vary
according to the needs and abilities of each student.
Students are responsible for maintaining standards of care and competencies achieved in prior
semesters. Students are required to be prepared and adapt to variations in the patient care
assignment.
Students will be oriented to their assigned clinical site by the clinical instructor. Expectations for
clinical performance and written clinical assignments will be included in the orientation.
General Policies:
All general policies in the Registered Nursing Program Handbook and the Northark Student
Handbook are adhered to in this course. Review the Registered Nursing Program Handbook for
this course. See the course coordinator or your clinical instructor if you have any questions.
Absence from clinical requires that the student notify appropriate persons. Clinical instructors will
describe the procedure for specific clinical sites. Make up clinical experiences will be done
during the assigned time at the end of the semester (during final exam week). Maximum of 12
clinical hours may be made up per semester. Any absences in excess of 12 hours will result in
dismissal from the program. (See attendance policy in the RN Program Handbook).
Accommodations for Students with Special Needs:
North Arkansas College complies with Section 504 of the Rehabilitation Act of 1973 and the
Americans with Disabilities Act of 1990. Students with disabilities who need special
accommodations should make their requests in the following way: (1) talk to your instructor after
class or during office hours about your disability or special need related to your classroom work;
and/or (2) contact Student Support Services in Room M149 and ask to speak to Kim Brecklein.
Student Responsibilities:
As a student at North Arkansas College, you share the responsibility for your success. The only
way you can benefit from the many opportunities offered to you by the college is by doing your
part.
As a student, you are responsible to:
1.
2.
3.
4.
Read the college catalog and all materials you receive during registration. These
materials tell you what the college expects from you.
Read the syllabus for each class. The syllabus tells you what the course expectations are
and how you can plan ahead.
Attend all class meetings. Something important to learning happens during every class
period. If you must miss a class meeting, talk to the instructor in advance about what you
should do.
Be on time. If you come in after class has started, you disrupt the entire class.
5.
6.
7.
8.
9.
10.
Never interrupt another class to talk to the instructor or a student in that class.
Be prepared for class. Complete reading assignments and other homework before class
so that you can understand the lecture and participate in discussion. Always have
pen/pencil, paper, and other specific tools for class.
Learn to take good notes. Write down ideas rather than word-for-word statements by the
instructor.
Allow time to use all the resources available to you at the college. Visit your instructor
during office hours for help with material or assignments you do not understand; use the
library; use the free tutors, tapes, computers, and other resources in Learning Assistance
Center.
Treat others with respect. Part of the college experience is being exposed to people with
ideas, values, and backgrounds different from yours. Listen to others and evaluate ideas
on their own merit.
Be able to identify course and clinical objectives. (These are found in the syllabus).
Provision for changing syllabus: Students will be notified on portal announcements and in
writing of any syllabus change.
Alterations in the Gastrointestinal System
Course Outcomes: 1-15
Objectives
After completion of this chapter, the learner should be able to
1. Compare the mechanical and chemical processes involved in digestion
and absorption of foods and elimination of waste products and possible
alterations in the process.
2. Employ assessment parameters appropriate for
determining the status of GI function.
3. Examine the patient preparation, teaching and
follow-up care appropriate for patients having
diagnostic testing of the GI tract.
4. Use the nursing process as a framework for
care of patients with conditions of the GI system.
5. Apppraise different types of nutrition on various alterations of the GI
system.
6. Analyze the psychosocial and cultural aspects regarding nutrition.
7. Categorize the various upper and lower GI system alterations using
the nursing process.
8. Using evidence based research, describe the risks and benefits of
special nutritional therapy.
9. Explore benefits and risks of surgical options related to the GI system.
10. Differentiate the nursing practice of patients with
various types of gastrointestinal tubes.
11. Explore team members involved in the care of patients with GI
disorders as well as proper delegation to those team members.
12. Employ therapeutic communication to teach self management to
patients and/or families regarding colostomy care.
13. Describe the effects of aging on the digestive system.
Content
I. Assessment of Digestive and Gastrointestinal
Function
a. Pathophysiological overview
b. Diagnostic tests
c. Nursing process
d. Gerontological considerations
II. Assessment and Management of Patients
with Upper Gastrointestinal Disorders
a. Oral Cavity Problems
b. Esophageal
III. Assessment and Management of Patients
with Lower Gastrointestinal Disorders
a. Stomach
b. Absorption
c. Noninflammatory intestinal d/o
d. Inflammatory intestinal d/o
III. Assessment and Management of Patients
Requiring Special Nutritional Therapy
a. Types of gastric tubes
b. Formulas for tube feedings
c. Dumping syndrome
d. Procedure for tube feedings
e. TPN
IV. Care of patients with Malnutrition and
Obesity
a. Calculate Body Mass Index
b. Risk factors
c. Enteral Feedings
d. Parenteral Feedings
e. Bariatric surgeries
f. Drug therapy
Learner Activities
Ignatavivius, M. and Workman,
L.
(2013)
Medical-Surgical
Nursing:
Patient-Centered
Collaborative Care, 7 th ed., St.
Louis, MO: Elsevier-Saunders.
Read chapters
View ATI skills module
-Nasogastric Intubation
-Enteral TubeFeedings
-Nutrition, Feeding, and
Eating
Powerpoint presentation
Audio/Visual
ATI Gastrointestinal review
questions
Class activity –
video
case scenarios
lab simulation
Calculate BMI
Mini Nutritional Assessment
Care of Patients with Problems of the Liver, Biliary System, and Pancreas
Course Outcomes: 1-15
Objectives
Content
Learner Activities
After completion of this chapter, the learner should be able to
Ignatavivius, M. and Workman, L. (2013) MedicalI. Assessment of Liver, Biliary system, and
pancreas
1. Explore the roles of the collaborative health care team
members to provide care for patients with liver, biliary
system and pancreatic problems.
2. Develop a patient centered teaching plan for patients and
families to prevent or slow the progress of alcohol induced
cirrhosis and pancreatitis.
3. Evaluate community resources related to alcohol abuse.
4. Using the nursing process, explore the nursing and
medical management of patients with liver, biliary system,
and pancreatic problems.
5. Compare and contrast the transmission and prevention of
hepatitis infections.
6. Analyze the psychosocial and cultural aspects regarding
the consumption of alcohol.
7. Categorize diagnostic and laboratory procedures related
to disorders of the liver, bilary system, and pancreas.
8. Using evidence based research, explore treatment
options for cancer of the liver, biliary system, and pancreas.
9. Identify risk factors for developing gallbladder, liver, and
pancreatic diseases.
10. Discuss legal and ethical situations related to
transmittable diseases.
.
a. Pathophysiological overview
b. Diagnostic tests
c. Nursing process
d. Gerontological considerations
II. Assessment and Management of Patients
with disorders involving the liver
a. Cirhosis
b. Hepatitis
c. Fatty Liver
d. Cancer of the Liver
e. Trauma
f. Complications associated
g. Pharmacology
Surgical Nursing: Patient-Centered Collaborative
Care, 7 th ed., St. Louis, MO: Elsevier-Saunders.
Read chapters 64-67
Powerpoint presentation
Audio/Visual
2 Nutrition ATI practice tests
Class activity –
video
case scenarios
Overview of pathophysiology and lab tests:
III. Assessment and Management of Patients
with Biliary System and pancreatic disorders
a. Cholecystitis
b. Acute and chronic pancreatitis
c. Pancreatic cancer
http://www.youtube.com/watch?v=BTGkB8nOu7g
Care of Patients with Diabetes and Endocrine disorders
Course Outcomes: 1-15
Objectives
After completion of this chapter, the learner should be
able to
1. Formulate a diet for patients with Diabetes
Mellitus Type I and 2 using the carbohydrate
counting method.
2. Differentiate management of diabetic
ketoacidosis (DKA) and hyperglycemichyperosmolar state (HHS).
3. Evaluate the role of quality improvement
related to management of diabetes.
4. Using the nursing process, explore the nursing
and medical management of patients with
diabetes and endocrine disorders.
5. Compare and contrast the different types drug
therapies for type 1 and 2 diabetes mellitus.
6. Explore community and online support groups
for disorders related to the endocrine system and
diabetes.
7. Value cultural differences when
communicating with patients regarding their
diagnosis.
8. Identify specific safety issues related to
endocrine disorders and diabetes clients.
9. Identify the role of the collaborative health
care team related to endocrine disorders and
diabetes.
10. Discuss ethical dilemmas that arise regarding
self management or lack of in clients with
diabetes and endocrine disorders.
Content
Learner Activities
I. Assessment of patients with Diabetes
and Endocrine Disorders
a. Pathophysiological overview
b. Diagnostic tests
c. Nursing process
d. Gerontological considerations
e. Risk factors
Ignatavivius, M. and Workman, L. (2013) Medical-Surgical
Nursing: Patient-Centered Collaborative Care, 7 th ed., St. Louis,
MO: Elsevier-Saunders.
II. Management of Patients with diabetes
a. Diabetes Mellitus Type I
b. Diabetes Mellitus Type 2
c. Complications
d. Pharmacology
Powerpoint presentation
Audio/Visual
III. Assessment and Management of
Patients with disorders of the
a. posterior pituitary gland
b. anterior pituitary gland
c. Adrenal gland
d. Thyroid gland
e. Parathyroid glands
f. Complications of these
disorders
g. Pharmacology
Read chapters 64-67
Endocrine ATI practice test
Class activity –
video
case scenarios
staging
Gordon’s Functional health Patters Endocrine Assessment
Discussion of Evidence Based Practice
National Guidelines for Type 2 Diabetes
http://www.guideline.gov/content.aspx?id=36628
National Guidelines for Pediatrics with Diabetes
http://pediatrics.aappublications.org/content/early/2013/01/23/peds.20123494.full.pdf
Care of Patients with Burns and Skin Disorders
Course Outcomes: 1-15
Objectives
After completion of this chapter, the learner should be
able to
1. Evaluate skin care delegated to LPN or
unlicensed assistive personnel (UAP)
2. Formulate a self management plan related to
skin disorders.
3. Explore evidence based research related to
risk factors and prevention associated with skin
disorders and burns.
4.Examine skin disorders and patients with burns
using the nursing process,
5. Identify infection control principles to prevent
spread of infections of the skin.
6. Diagram cultural influences regarding the
integumentary system.
7. Value cultural differences when
communicating with patients regarding their
diagnosis.
8. Use therapeutic communication while
supporting patients and families in coping with
changes in appearance and function.
9. Compare the manifestations of superficial,
partial-thickness, and full-thickness burn injuries.
10. Collaborate with healthcare team members
during the rehabilitation phase of burn injury.
11. Ethical dilemmas surrounding plastic surgery.
Content
Learner Activities
I. Assessment of patients with Burns and
disorders of the skin
a. Pathophysiological overview
b. Diagnostic tests
c. Nursing process
d. Gerontological considerations
e. Risk factors
Ignatavivius, M. and Workman, L. (2013) Medical-Surgical
Nursing: Patient-Centered Collaborative Care, 7 th ed., St. Louis,
MO: Elsevier-Saunders.
II. Management of Patients with burns
a. Types of burns
b. Priorities following burns
c. Rule of nines
d. Risk factors
e. Associated problems
f. Wound and graft care
Powerpoint presentation
Audio/Visual
III. Assessment and Management of
Patients with disorders of the skin
a. Types of skin disorders
b. Trauma
c. Pressure ulcers
d. Cutaneous antrax
e. Parasites and mites
f. Skin cancers
g. Surgical procedures
Read chapters 26-28
50 NCLEX questions related to skin disorders and burns
Class activity –
video
case scenarios
concept mapping
Braden Scale for pressure ulcer risk
Discussion of Evidence Based Practice
Care of Patients with Anxiety, Mood Disorders, & Schizophrenia
Course Outcomes: 1-15
Objectives
After completion of this chapter, the learner should be
able to
1. Examine barriers to treatment in the homeless and
incarcerated population.
2. Use therapeutic communication with clients
experiencing mental illness.
3. Explore the Diagnostic and Statistical Manual of
Mental Disorders (DSM V) as the standard
classification of mental disorders.
4. Identify the roles of different health care team
members involved with patients with mental health
disorders.
5. Consider the legal and ethical issues related to
restraints and seclusion.
6. Discuss the defense mechanisms for coping with
anxiety.
7. Evaluate safety concerns when dealing with
patients with mental disorders.
8. Compare and contrast different phobias and mood
disorders.
9. Evaluate community resources both inpatient and
outpatient settings related to clients suffering mental
illnesses.
10. Formulate a comprehensive teaching plan related
to anxiety and mood disorders.
Content
Learner Activities
I. Assessment of patients with anxiety and
mood disorders and schizophrenia
II. Management of Patients with anxiety
disorders
a.
b.
c.
d.
Etiologies
Types of anxiety disorders
Signs and symptoms
Pharmacological and
nonpharmacological treatments
III. Management of Patients with mood
disorders
a. Etiologies
b. Types of mood disorders
c. Signs and symptoms
d. Pharmacological and
nonpharmacological treatments
IV. Management of patients with
schizophrenia
a. Etiologies
b. Positive and negative
symptoms
c. Pharmacological and
nonpharmacological
treatments
ATI chapters regarding:
Anxiety, Mood Disorders, & Schizophrenia
Powerpoint presentation
Audio/Visual
ATI Mental health Practice Tests
Class activity –
video
role play
Connect: game of connecting pharm and non pharm treatments
to the diagnosis
Care of Patients with alterations in the Immune System
Course Outcomes: 1-15
Objectives
After completion of this chapter, the learner should be
able to
1. Discuss safety issues related to patients with
immune system disorders.
2. Formulate a self management plan related to
patients experiencing immune system
alterations.
3. Explore evidence based research related to
risk factors and prevention associated with
immune disorders.
4.Examine the effects of medication on a variety
of immune disorders.
5. Identify infection control principles to prevent
the spread of infections.
6. Formulate a teaching plan for patients and
families associated with immune disorders.
7. Ethical dilemmas surrounding HIV.
8. Use therapeutic communication while
supporting patients and families in coping with
the diagnosis of a chronic immune disorder.
9. Compare and contrast immune disorders
using the nursing process.
10. Examine the roles of healthcare team
members involved in caring for patients with
immune disorders.
11. Identify community resources for patients
experiencing immune system disorders.
Content
I. Assessment of patients with
alterations in the immune
system
a. Pathophysiological
overview
b. Diagnostic tests
c. Nursing process
d. Gerontological
considerations
e. Risk factors
II. Management of Patients with
a. HIV
b. Allergic disorders
c. Rheumatic disorders
d. Other immune
disorders
Learner Activities
Ignatavivius, M. and Workman, L. (2013) Medical-Surgical Nursing: PatientCentered Collaborative Care, 7 th ed., St. Louis, MO: Elsevier-Saunders.
Read chapters 19-22 and 25
Powerpoint presentation
Audio/Visual
Immune ATI Practice ID 5554142 Test
Immune ATI Practice ID 5689835 Test
Class activity –
video
case scenarios
concept mapping
Discussion of Evidence Based Practice
Evidenced Based Guidelines from Centers for Disease Control and Prevention
(CDC) HIV
http://www.cdc.gov/hiv/guidelines/index.html
Evidenced based Guidelines from American College of Rheumatology
http://www.rheumatology.org/Practice/Clinical/Guidelines/Clinical_Practice_Guidelines/
Clinical Section
What is SBAR and What is SBAR Communication?
A Communication Technique for Today's Healthcare Professional
Situation Background Assessment Recommendation (SBAR) is a standardized way of
communicating. It promotes patient safety because it helps individuals communicate with
each other with a shared set of expectations. Staff and physicians can use SBAR to share
patient information in a concise and structured format. It improves efficiency and accuracy.
SBAR stands for:

Situation

Background

Assessment

Recommendation
Originally developed by the US Navy as a communication technique that could be used on nuclear submarines, Safer Healthcare introduced
SBAR into healthcare settings in the late 1990s as part of its Crew Resource Management training curriculum. Since that time, SBAR has been
adopted by hospitals and care facilities around the world as a simple but effective way to standardize communication between care givers.
Standardize Communication among Staff and Caregivers
SBAR offers hospitals and care facilities a solution to bridge the gap in communication, including hand-offs, patient transfers, critical
conversations and telephone calls. It creates a shared expectation between the sender and receiver of the information being shared.
Example:
Introduction

Dr. Jones, this is Deb McDonald RN, I am calling from ABC Hospital about your patient Jane Smith.
Situation

Here's the situation: Mrs. Smith is having increasing dyspnea and is complaining of chest pain.
Background

The supporting background information is that she had a total knee replacement two days ago. About two hours ago she began
complaining of chest pain. Her pulse is 120 and her blood pressure is 128/54. She is restless and short of breath.
Assessment

My assessment of the situation is that she may be having a cardiac event or a pulmonary embolism.
Recommendation

I recommend that you see her immediately and that we start her on 02 stat. Do you agree?
http://www.saferhealthcare.com/sbar/what-is-sbar/
NURSING 2104
Medical-Surgical Nursing II
Must have the following BEFORE clinical rotation:
Current TB skin test
• MMR
Current CPR
• Varicella (chickenpox)
• Hepatitis series
CLINICAL OUTCOMES
Throughout the NURS 2104 clinical rotation, the nursing student will:
Human Flourishing
1. Practice patient centered care using correct assessment techniques and safe performance of nursing
skills.
2. Utilize effective therapeutic communication skills with patients, families, healthcare team, and others.
3. Provide a safe physical and psychosocial environment for the patient that demonstrates cultural
competence.
Nursing Judgment
4. Use evidence based practice to establish a written plan of care for selected patients using the Nursing
Interventions Classification (NIC) and Nursing Outcomes Classification (NOC). Use clinical reasoning to
evaluate you plan.
5. Practice safety in maintaining fluid and nutritional balance for medical surgical patients.
6. Use safe medication practices to explain the therapeutic action, nursing implications, and adverse effect
of all medications administered.
7. Teamwork cooperatively with others to achieve patient and organizational outcomes.
8. Analyze the effectiveness of managing care provided in meeting patient outcomes.
Spirit of Inquiry
9. Demonstrate clinical reasoning when using the nursing process to provide knowledgeable, safe, and
patient centered care.
10. Recognize and explain styles of leadership, communication patterns, and delegation decisions
observed/experienced in the management of nursing units and the delivery of patient care.
11. Contrast and compare changes, challenges, and current trends in health-care systems that require
clinical decision-making, management skills, and collaboration.
Professional Identity
12. Utilize informatics to report and document assessments, interventions, and progress toward patient
outcomes.
13. Discuss the purpose for diagnostic procedures and utilize teaching skills to provide information to patient
and family.
14. Apply legal and ethical principles in caring for assigned patients both in acute care and community
settings.
15. Maintain strict patient confidentiality at all times according to the health Insurance Portability and
Accountability Act (HIPAA) regulations
Things you must know upon arrival to a new clinical area:
• Location of fire alarm pull stations
• Location of PPE
• Location of fire extinguishers
• Location of Crash Cart
• Evacuation routes
EACH CLINICAL ASSIGNMENT IS DUE PER CLINICAL INSTRUCTOR'S DIRECTION.
**It is the clinical instructor’s discretion whether or not to except late assignments.**
GI LAB WRITTEN ASSIGNMENT
1.
What is an EGD? What is the purpose of this procedure? Describe the pre- and postprocedure nursing care of a patient having this procedure.
2.
Differentiate between proctoscopy, sigmoidoscopy and colonoscopy.
3.
Identify pre- and post-procedure nursing measures in caring for the patient having a
colonoscopy.
4.
Describe the responsibilities of the RN in the GI lab and the skills needed to fulfill
responsibilities.
HEALTH CLINIC WRITTEN ASSIGNMENT
1.
Explain the purpose of the health clinic.
2.
Identify the services provided at the clinic.
3.
Describe the role and responsibilities of:
a. the nurse practitioner
b. the staff nurse in the clinic setting.
4.
Write a brief summary of your experience. Include:
a. purpose of patient’s visit to clinic.
b. care provided.
c. teaching done by the nurse.
HOME HEALTH WRITTEN ASSIGNMENT
1.
Define Home Health and its purpose.
2.
Describe the use of the nursing process when making a home health visit.
3.
Explain the eligibility requirements for receiving home health services.
4.
Assess the physical and psychosocial environment of the home of one of the patients you visit.
Based on your findings, identify risk factors for health maintenance. Assess need for patients
home modifications (e.g., lighting, handrails, kitchen safety, etc.).
5.
Observe and describe the interaction between the nurse and a specific patient.
6.
Discuss the nurse’s interdisciplinary collaboration with other healthcare providers (i.e.:
physical therapists, speech therapists, social worker, dietitians, occupational therapists,
respiratory therapists, or pastoral minister, etc.).
7.
Educate patient on home safety issues.
Journaling
A reflective journal is meant for the writer to be able to think back about an experience learn about the meaning
of the experience. As nursing students, journaling can help you learn about yourself, a disease process, discover
holistic approach to nursing, how to really find value and demonstrate care to a patient or their family, discover
mistakes and make corrections. Journaling will teach you how to internalize your learning and make it real.
For each clinical date you are to keep a journal. The journal is due every two weeks beginning two weeks after
the start of clinical. Submit your journal to your clinical instructor.
Guidelines:
 You may either handwrite or type the entry.
 No need to write a book; unless you need to.
 Ideas about entries:
o New skills practiced or attempted
o RN professional practices that you noticed
o Your thoughts and feelings in regard to your actions or another's actions, and interactions you
noticed between staff and between staff and patients
o Give examples of caring expressions, either by you or someone else
o Document ethical, cultural, legal encounters you experience and interventions
o Discuss organization, prioritization, and delegation related to patient care
o Discuss how you used therapeutic communication and collaboration in relation to a patient
situations
o What did you learn about social services and community resources
OUTPATIENT SURGERY WRITTEN ASSIGNMENT
During the rotation, the nursing student will complete the following writing:
1.
Describe the difference in nursing responsibilities for the patient facing outpatient surgery and the
patient facing in-hospital surgery.
2.
Explain the significance of the surgical prep and the importance of technique.
3.
Describe the technique for administering pre-op meds and the nursing responsibilities before and after
administration.
4.
Prepare drug cards on all drugs administered.
5.
Discuss the nursing responsibilities of caring for the pediatric surgical patient.
6.
Assess the need for family support and education, and identify a plan for meeting this need.
7.
Explain the assessment of and documentation for patients returning to OPSU.
8.
Prepare a teaching plan for an individual having outpatient surgery.
9.
Discuss the discharge criteria to determine a patient's readiness to go home.
10.
Examine the legal implications for the nurse in discharging patients who have received medication
and/or anesthesia.
NORTHARK HEAD-TO-TOE ASSESSMENT
Date:
Sex: M / F
Age:
Fluids/Rate:
IV site/Gauge
Vital Signs:
Admitting Diagnosis:
Diet / I & O:
Drains/Tubes (NG, etc)
General Inspection
Neurological / Mental
IV Site: ☐Asymptomatic☐Tenderness ☐Discoloration☐Localized
Edema
LOC: ☐Awake ☐Alert ☐ Not alert
Oriented to: ☐Person ☐Place ☐Time ☐Situation
Mental Status: ☐Calm ☐Anxious ☐Fearful
☐ Depressed ☐Other: ____________________________
Pupils: Left: ☐Equal ☐Reactive ☒mm ________
Right ☐Equal ☐Reactive ☐mm________
Speech:☐Clear ☐Aphasic☐Slurred ☐Appropriate☐Inappropriate
Gait: ☐Shuffling
☐Steady
Head: ☐Symmetrical
☐ Non-tender
PAIN
Skin: ☐ Intact ☐ Dry/Warm ☐ Pink ☐ Cyanotic ☐ Icteric
☐ Cool/Clammy ☐ Diaphoretic ☐Lesions ☐ Petechiae
Head: ☐Symmetrical ☐Asymmetrical ☐ Masses
☐ Non-tender ☐Tender ☐Neck supple ☐ Full ROM
Hair: ☐Evenly distributed ☐Shiny luster
☐ Dry scalp
☐Balding
☐ Scalp Lesions
Eyes: ☐Symmetrical ☐Asymmetrical ☐ Drainage ☐Blind
☐ No Drainage ☐Edema/lid tag/redness ☐glasses/contacts
Ears: ☐Symmetrical ☐Asymmetrical ☐ Otorrhea
☐ Lesions/redness/tenderness/edema ☐Hearing Aids (L,R,B)
Nose: ☐Symmetrical ☐Nares Patent ☐ Rhinorrhea
☐ Obstruction: ____ R nare
____L nare
Mouth: ☐Lips moist ☐Lips dry/cracked ☐ Sores/bleeding
☐ Mucous dry ☐Teeth missing ☐Dentures ☐Gums pink/intact
☐Right-handed
☐Left-handed
☐Unable to assess
☐Non-ambulatory
☐Asymmetrical ☐ Masses
☐Tender ☐Neck supple ☐ Full ROM
Pain Scale (circle): 0 1 2 3 4 5 6 7 8 9 10
Description: ☐No pain ☐Sharp
☐Pressure ☐Dull
☐Ache
☐Burning ☐Chronic ☐Acute
Location:
Cardiovascular
Respiratory
Pulses: Rate: ____ ☐Right Radial ☐Left Radial
☐ Apical
☐Right Pedal ☐ Left Pedal ☐Right Carotid ☐Left Carotid
☐Bruits (carotids) Right OR Left
Amplitude____ (1+ weak, 2+ strong , 3+bounding)
Rhythm: ☐Regular ☐Irregular
Capillary Refill: ☐ Less than 3 sec
Blood Sugar:
☐More than 3 sec
Skin Turgor: ☐Elastic ☐Tenting ☐Clubbing
Edema: ☐ No Edema ☐Edema Location: __________________
☐Pitting Edema:☐2+ ☐3+ ☐4+ ☐Nonpitting (brawny)
Breath Sounds: ☐Clear
☐Crackles ☐ Rhonchi ☐ Diminished
☐Inspiratory Wheezes ☐Expiratory Wheeze
Location: ☐RUL
☐RML ☐RLL
☐LUL
☐LLL
Cough: ☐No cough ☐Productive ☐Non-productive ☐Frequent
☐Occas.
Sputum: Color: ______________ Consistency:
______________________
Oxygen: ☐Yes ☐No
Rate:_________ Delivery: __________
☐Nasal Cannula (NC) ☐Non-rebreather (NRB) ☐High flow NC
☐Vent
☐Veni-mask
☐CPAP
☐Bi-Pap
Gastrointestinal
Genitourinary/Renal (GU)
Abdomen: ☐ Non-tender ☐ Tender ☐Distended ☐Flat
☐Soft
☐Firm
☐Ascites
Bowel Sounds: ☐Active ☐Inactive ☐Hypoactive ☐Hyperactive
Quadrants: ________________________________
Tube: ☐NGT: : ☐G-Tube
☐Suction ☐Clamped ☐Intermittent ☐Gravity ☐Continuous
Residual: _______ml
☐Placement checked
Formula: ______________________ Rate: _____________
Stoma: ☐Colostomy ☐Ileostomy☐Pink ☐Red ☐Blue/Black
LBM: ________ ☐Soft ☐Formed ☐Hard ☐Loose ☐Bloody
☐ Brown ☐Continent ☐Incontinent ☐Other: ____________
Wounds
Site:____________ ☐Drainage ☐Dressing Intact ☐Sutures ☐Drain
Voids:☐BRP ☐Catheter Size: ________FR
Bladder: ☐Distended
☐Non-distended
Urine: ☐Clear ☐Yellow ☐Amber ☐Other: __________________
☐Continent ☐Incontinent
Psychosocial-Cultural
Living Arrangement: ☐Alone ☐With spouse ☐With children
☐Nursing Home ☐Assisted Living ☐Homeless ☐Rehab
Cultural Concerns:
Spiritual Concerns:
Occupation/Retired:
Erickson’s Stage:
General Concerns:
Tobacco/Alcohol Use or Exposure:
Musculoskeletal
ROM: Upper body: ☐Full ☐Limited ☐Left Side ☐Right Side
Lower body: ☐Full ☐Limited ☐Left Side ☐Right Side
Grips/Extremity Strength: RIGHT ☐Strong ☐Weak ☐Equal
LEFT ☐Strong ☐Weak ☐Equal
☐Contractures ☐Arthritis ☐Amputation – Location___________
☐Splint – Location _______________________________________
Pulses distal to placement: ☐Intact ☐Not intact
☐Fall Precautions ☐Fall precaution interventions in place
Assistive Devices:☐Walker ☐Cane ☐Quad Cane ☐Trapeze
☐Crutches ☐Wheelchair ☐TED hose ☐Flowtrons
Student Name ____________________________________
Date_____________________
Client Age_____ Allergies_________________________________________________________
Date of Patient Admit/Surg __________________________________________ M/F__________
CRITICAL THINKING FOR CLINICALS
Primary medical diagnosis and brief pathophysiology:
______________________________________________
________________________________________________________________________________
_____
________________________________________________________________________________
_____
________________________________________________________________________________
_____
________________________________________________________________________________
_____
________________________________________________________________________________
_____
________________________________________________________________________________
_____
________________________________________________________________________________
_____
Lab/Diagnostics:
Lab: H & H______________________ WBC_____ K+_____ N+_____ Glucose_____
BUN____________
PT,, PTT, INR ______ RBC______ Blood Cultures______ MIC
(S/R)________________________
Cardiac Markers (troponin, CKMB)_____ BNP_____ D-Dimer_____
Creatinine________________
Urinalysis_______________ Ketones_______ Urine Cultures___________
Myoglobin__________
Phenytoin____________ Digoxin_______ Lipase______ Amylast_____ Occult
stool___________
H-pylori__________ Liver Enzymes__________
ABGs___________________________________
(try to determine if your patient was alkalotic or acidotic, why is this
important?)_________________
HDL__________ LDL__________
*Add other lab values specific to your patient
______________________________________________
______________________________________________________________________________
Which ones will you continue to monitor R/T medical dx or meds?
________________________________
Compare to previous draws or collections? Note any change.
____________________________________
__
______________________________________________________________________________
_____
__
______________________________________________________________________________
_____
Radiology (C-T scans, films, MRI, Ultrasound)? Why were these done? What were the results and
how were they used to diagnose or determine treatment?
___________________________________________
_
______________________________________________________________________________
_______
______________________________________________________________________________
______
______________________________________________________________________________
______
______________________________________________________________________________
______
Any PRNs? Just list and note if patient has needed them.
______________________________________
________________________________________________________________________________
_____
________________________________________________________________________________
_____
Equipment? Vent, Monitors, Drains, Wound Vac, Foley, Bi-Pap, Pumps, Central Lines, defibrillators,
pacemakers, stimulators, implants, prostheses or reconstructive hardware; Treatments? Respiratory
treatments; GI procedures; stress tests, etc.
_____________________________________________________________________
________________________________________________________________________________
_____
Medications for Critical Thinking Clinical Assignment
Drug Name
Generic/Trade
Class
Adult
Dosing
*note if
specific
for renal,
cardiac,
etc.
Routes
Uses
Actions
Specific
Side
Effects
Nursing Considerations
 Drug/food
 Interactions
 Labs to monitor
 Pre-Assessment
 How to administer
 Client teaching
Why used with
your patient
Identify 2- 3 priority nursing diagnosis. One may be a psychosocial.
Nursing Diagnosis 1
(Related to AEB)
Outcome Desired
DX:
Specific Interventions with rationale
(you have done to impact this outcome)
Actual Outcome observed
at end of shift
1.
Rationale:
2.
R/T:
Rationale:
3.
AEB:
Rationale:
4.
Rationale:
Nursing Diagnosis 2
(Related to AEB)
Outcome Desired
DX:
Specific Interventions with rationale
(you have done to impact this outcome)
Actual Outcome observed
at end of shift
1.
Rationale:
2.
R/T:
Rationale:
3.
AEB:
Rationale:
4.
Rationale:
Nursing Diagnosis 3
(Related to AEB)
DX:
Outcome Desired
Specific Interventions with rationale
(you have done to impact this outcome)
1.
Rationale:
R/T:
AEB:
2.
Rationale:
3.
Rationale:
4.
Rationale:
Actual Outcome observed
at end of shift
Related Concepts
Priority Nursing
Interventions
Priority Problem(s)
Priority
Assessments
Think Outloud
Related Labs
Priority Teaching/ Discharge Goals
Registered Nursing Program
Clinical Warning Form
Definitions & Procedures
S = Satisfactory
Students meet minimum requirements for the program outcomes.
N = Needs Improvement
Students did not meet minimum requirements for 1 or more core competency for that program
outcome. If an N is received then the student and instructor are expected to:
1. Discuss the issue during the clinical rotation.
2. The instructor will document the discussion on the clinical formative evaluation tool.
3. The instructor will fill out the clinical warning form.
4. The student will formulate a simple remediation plan to be presented to the clinical instructor
and course coordinator. (if applicable)
5. If after remediation, the student receives another N, the process will be repeated once more.
6. If the student receives 3 N’s in the same program outcome category, such as Human
Flourishing, on separate occasions during a course clinical rotation then they will receive a U
for that clinical rotation and will be dismissed from the program.
U= Unsatisfactory (3 N’s)
Student did not demonstrate essential skills for patient safety, professional behavior etc. as
stated on page 37 in the RN Handbook. If the student participates in any of the reasons for dismissal
as listed under “Unsafe Clinical Practice” if the RN Handbook they will receive a U on the clinical
formative evaluation tool.
North Arkansas College
Department of Nursing
Clinical Warning Form
Student Name__________________________________
Clinical Rotation___________________
The above student has received a “Needs Improvement” evaluation from the clinical instructor. The following
area(s) was/were designated as not meeting the minimal requirement.
(circle)
Human Flourishing
Communication,
Cultural Diversity
Patient Centered Care,
Nursing Judgment/Practice
Safety/Quality Improvement,
Managing Care,
Evidence Based Practice,
Collaboration/Teamwork
Spirit of Inquiry
Clinical Decision Making,
Professional Identity
Professional Behavior,
Informatics,
Clinical Reasoning
Teaching-Learning,
Legal-Ethical
Specific area needing improvement –
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Student’s plan for remediation –
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I acknowledge that I have read and understand the above clinical evaluation.
Student____________________________________________________
Date_______________
Instructor__________________________________________________
Date_______________
Course Coordinator_________________________________________
Date_______________
INC 10-24-12
*Copy given to student, copy to instructor and/or course coordinator, original in student file.
Revised 4-12
10-24-12
North Arkansas College
Department of Nursing RN Program
Formative Evaluation Tool
Student Name____________________________________________
Clinical
Rotation_______________________________________________
S = Satisfactory
N = Needs Improvement U = Unsatisfactory
Human Flourishing
Fill in Clinical Dates HERE
Communication
Uses effective therapeutic communication skills with patients, health care team,
faculty and others
Actively participates in pre/post conferences
Documents appropriately in either writing or in the electronic health record
Patient Centered Care
Assess/plan for patient-family spiritual needs
Respects the individual’s personal spirituality
Assists the patient to meet their spiritual outcomes
Demonstrates compassion for others
Cultural Diversity
Respects & values diverse cultures
Provides culturally competent care
Nursing Judgment/Practice
Safety/Quality Improvement
Uses standard precautions, hand hygiene and sterile technique
Administers medications using the 6 rights
Able to verbalize action, side effects, adverse reactions of medications
Recognizes and intervenes for high risk patients
Provides for a safe environment for self, others and patients
Recognizes their role in a disaster preparedness
“Identifies” quality improvement measurements
Evidence Based Practice
Utilizes the nursing process to provide patient care
Uses correct assessment techniques
Identifies appropriate nursing diagnosis
Plans patient care using current trends in health care
Performs appropriate nursing interventions
Evaluates patient outcomes and revises care as needed
Managing Care
Prioritizes patient care
Provides timely patient care
Demonstrates organizational skills
Completes assignments on time
Collaboration/Teamwork
Identifies members of the health care team (lower level)
Compares the roles of the health care team (medium)
Plans patient care with the health care team (higher level)
Provides assistance to other health care team members
Functions as a team member by demonstrating cooperativeness & displaying mutual
respect
Semester__________________
Course____________________
_
NA = Not Applicable
Professional Identity
Spirit of Inquiry
Fill in Clinical Dates HERE
Clinical Decision Making
Makes clinical judgments to ensure safe care
Uses evidence-based information to evaluate patient outcomes
Identifies problems, issues, and risks to promote health and safety
Seeks out learning opportunities
Explores alternatives to achieve patient goals
Clinical Reasoning
Questions underlying assumptions
Offers new insight to improve quality of care
Professional Behaviors
Professional appearance (uniform and hygiene)
Preparedness (comes to clinical with stethoscope, name tag, pen, etc)
Demonstrates positive attitude
Role model for others
Notifies clinical instructor of absence/tardiness per policy
Does not show pattern of tardiness/absenteeism
Accepts criticism and corrects mistakes willingly
Is self-motivated and directed
Complies with agency and program policy
Teaching and Learning
Utilizes evidence-based teaching interventions
Demonstrates mutual goal-setting
Identifies resources (physical, emotional, spiritual, etc.)
Promotes self-determination of patient and self
Informatics
Utilizes technology to provide safe patient care
Access appropriate resources to support positive patient outcomes
Legal/Ethical
Practices with in the identified role of a student nurse
Maintains confidentiality (HIPAA)
Clinical Instructor Initial HERE
Instructor Comments:
Instructor Signature:__________________________________________ Date:___________________
Student Comments:
I acknowledge that I have read and understand the above clinical evaluation.
Student Signature:___________________________________________ Date:_____________________
North Arkansas College
Department of Nursing RN Program
Summative Evaluation Tool
Revised 10-12
10-24-12
Human Flourishing
Student Name_____________________________________
Clinical
Rotation____________________________________________
S = Satisfactory
N = Needs Improvement U = Unsatisfactory
Communication
Uses effective therapeutic communication skills with patients, health care team, faculty
and others
Actively participates in pre/post conferences
Documents appropriately in either writing or in the electronic health record
Patient Centered Care
Assess/plan for patient-family spiritual needs
Respects the individual’s personal spirituality
Assists the patient to meet their spiritual outcomes
Demonstrates compassion for others
Cultural Diversity
Respects & values diverse cultures
Provides culturally competent care
Safety/Quality Improvement
Uses standard precautions, hand hygiene and sterile technique
Administers medications using the 6 rights
Able to verbalize action, side effects, adverse reactions of medications
Recognizes and intervenes for high risk patients
Provides for a safe environment for self, others and patients
Recognizes their role in a disaster preparedness
“Identifies” quality improvement measurements
Nursing Judgment/Practice
Evidence Based Practice
Utilizes the nursing process to provide patient care
Uses correct assessment techniques
Identifies appropriate nursing diagnosis
Plans patient care using current trends in health care
Performs appropriate nursing interventions
Evaluates patient outcomes and revises care as needed
Managing Care
Prioritizes patient care
Provides timely patient care
Demonstrates organizational skills
Completes assignments on time
Collaboration/Teamwork
Identifies members of the health care team (lower level)
Compares the roles of the health care team (medium)
Plans patient care with the health care team (higher level)
Provides assistance to other health care team members
Functions as a team member by demonstrating cooperativeness & displaying mutual
respect
Semester__________________
__
Course____________________
__
S, N,
U, NA
NA = Not Applicable
Instructor Comments
Spirit of Inquiry
Clinical Decision Making
Makes clinical judgments to ensure safe care.
Uses evidence-based information to evaluate patient outcomes.
Identifies problems, issues, and risks to promote health and safety.
Seeks out learning opportunities
Explores alternatives to achieve patient goals
Clinical Reasoning
Questions underlying assumptions
Offers new insight to improve quality of care
Professional Identity
Professional Behaviors
Professional appearance (uniform and hygiene)
Preparedness (comes to clinical with stethoscope, name tag, pen, etc)
Demonstrates positive attitude
Role model for others
Notifies clinical instructor of absence/tardiness per policy
Does not show pattern of tardiness/absenteeism
Accepts criticism and corrects mistakes willingly
Is self-motivated and directed
Complies with agency and program policy.
Teaching and Learning
Utilizes evidence-based teaching interventions
Demonstrates mutual goal-setting
Identifies resources (physical, emotional, spiritual, etc.)
Promotes self-determination of patient and self
Informatics
Utilizes technology to provide safe patient care
Access appropriate resources to support positive patient outcomes
Legal/Ethical
Practices with in the identified role of a student nurse
Maintains confidentiality (HIPAA)
PASS
FAIL
Student Comments:
I acknowledge that I have read and understand the above clinical evaluation.
Student Signature:__________________________________________
Date:_____________________
Instructor Signature:________________________________________
Date:_____________________