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NEO 114
Fall 2011
Family Nursing Clinical
North Seattle Community College
Course Syllabus
Course Prefix and Number: NEO 114
Course Title: Family Nursing Clinical
Course Credits: 5
Course Start Date: September 26, 2011
Course Location: Northwest Hospital Medical Center
Course Times: 6:30am- 6:30pm
INSTRUCTOR INFORMATION:
Margaret Johnston, RN-BC, BSN, M.Ed.
Email: johnstonmm@earthlink.net
margaret.johnston@seattlecolleges.edu
Phone: 206-265-9907
Kristi Cunnington, RN-BC, BSN, CDE
Email: akjjj@aol.com
Phone: 425-466-8119
Jessica Gonzales RN, BSN, MSN
Email: jessicagonzales0203@hotmail.com
Phone: 425.761.7224
Email or text messaging is the best and quickest way to reach us. We will make every effort to
get back to you within 24 hours. If there is an emergency, or if you will be absent from clinical,
for any reason, a phone call is required.
TEACHING PHILOSOPHY: As the instructors for this course, we believe it is our job to
foster a safe learning environment, to provide experiences that will facilitate achievement of the
course outcomes, to clearly communicate expectations, and to provide constructive evaluation. It
is our expectation that each student will assume responsibility for their own learning by
completing all of the reading assignments and activities provided as well as actively participating
in clinical. It is the student’s responsibility to seek instructor or preceptor guidance and support
in performing nursing care.
COURSE DESCRIPTION
Provides opportunities to build on previously learned skills and apply knowledge gained in NEO
104 through expanding the performance of nursing care in the role of caregiver, collaborator of
care, decision-maker, communicator, teacher and professional, into care of the family.
COURSE Skills goals:
1. Plan and implement care for clients with normal and complex conditions in labor and
delivery and postpartum while meeting clinical evaluation criteria
2. Observe therapeutic interventions in labor and delivery and postpartum
3. Complete physical and psychosocial assessment of families
4. Apply therapeutic communication skills
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5. Implement the nursing process in the care of clients with complex conditions
6. Demonstrate effective, independent, problem solving skills in the care of clients with
complex and well conditions
7. Demonstrate ability to collaborate with other members of the healthcare team.
8. Plan and implement safe and effective nursing care in antepartum, labor and delivery,
SCN, and postpartum units
9. Perform assessment of antepartum, labor and delivery, neonatal, and postpartum
patients
10. Identify and describe communication strategies for interviewing labor and delivery
and postpartum
11. Perform nursing skills in a safe and effective manner that demonstrates a caring ethic
in labor and delivery, antepartum, postpartum, nursery care and pediatric care settings
12. Assess current knowledge level, learning readiness, and developmental level of client
in regard to her health status
13. Utilize appropriate channels of communication with client, family, faculty, preceptor
and staff
14. Collaborate with healthcare team to develop plan of care to achieve desired outcomes
15. Adhere to standards of professional practice in nursing
16. Identify and separate self issues from those of clients
NSCC General Learning outcomes and/or Related Instructional Outcomes (for Technical
courses) met by this course:
Outcome 2. Intellectual and Practical Skills. Critical thinking and problem solving.
Communication and self-expression. Quantitative reasoning. Information literacy. Technological
proficiency. Collaboration: group and team work.
Outcome 4. Integrative and Applied Leaning. Synthesis and application of knowledge, skills,
and responsibilities to new settings and problems.
Course Outcomes/Learning Objectives:
1. Holistically care for the medical-surgical and psychiatric adult within an ethical, legal and diverse
framework under the designated health care provider within the scope of practice of the practical
nurse.
2. Demonstrate competency in educating and communicating with the medical-surgical and
psychiatric adult patient, patient families and the health care team.
3. Demonstrate competency in data gathering, problem identification, planning, implementing
nursing care and contributing to evaluation within a variety of settings utilizing appropriate
technology for the medical-surgical and psychiatric adult.
4. Use critical thinking to identify normal and abnormal patterns in the medical-surgical and
psychiatric patient, children and childbearing families based on understanding anatomy,
physiology, pathophysiology in order to contribute to the safe management of all patient care.
5. Effectively delegate and collaborate with the medical-surgical and psychiatric patient, patient’s
family and healthcare team
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COURSE POLICIES:
Conform to NSCC policies regarding appearance and professional behavior at all times.
Come to clinical prepared. You are not to perform any procedure (giving meds, dressing
changes, catheters etc) without notifying your instructor or preceptor first. Failure to do so will
result in immediate dismissal for the day, followed by disciplinary action.
The role of the clinical instructor is one of instruction and evaluation. It is the student’s
responsibility to seek instructor guidance and support in performing nursing care.
For a positive clinical experience it is recommended to bring a nursing drug reference and care
plan reference. Come to clinical prepared. This means being able to develop a plan of care for
your assigned patient and to answer questions about your client's diagnosis, medications, and
therapy with your instructor each day. It also means having the appropriate equipment and the
ability to research or provide the appropriate data. Course expectations are the following:
Arrive on time
Come prepared
Ask for help
Use each other as resources
Actively participate in discussion
Communicate information clearly to staff, instructor, team, patients and families
Use your critical thinking skills to the best of your ability when making decisions about patient
care
Check in with instructor/preceptor prior to meal breaks
ATTENDANCE/TARDINESS POLICY
All students must attend all laboratory and clinical/lab sessions, arrive on time, attend the class
during all assigned class hours, and be prepared to actively participate. Any scheduled laboratory, or
clinical/laboratory time missed will be considered an absence. Students are expected to attend all
orientation classes.
Theory course instructors may implement their own course attendance policy which can be found in
the course syllabus. Students will need to comply with their instructors attendance policy if
applicable.
Guidelines:
1. Absences will jeopardize meeting daily objectives, and therefore, success.
2. A student is allowed one medical or family emergency absence from clinical/lab each quarter not
to exceed 33% of that clinical/laboratory experience (for example, if OB is 3 days, a student can not
miss more than 1 day for emergency purposes, and pass the course ). Any additional absences OR a
tardy greater than 45 minutes OR absences that are not a medical emergency (unexcused) will result
in a 0 for the day which in clinical/lab may result in failing the course.
3. Two tardies of greater than 5 minutes in clinical/laboratory will constitute an absence, and a zero
for the day which may result in failing the clinical/laboratory course.
4. There is no scheduled “make up” laboratory or clinical days.
5. In the case of an absence, the student must:
a. Call their instructor a minimum of 1 hour before the start of clinical/lab, and report the absence
and state the reason why. Sending a message with a fellow student will not be accepted.
b. Provide a note in writing to the Director of Nursing explaining the reason for the absence.
c. Any injuries, or change in health status requires a healthcare provider‟s release to attend clinical,
and lab courses.
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A “No Call, No Show” is a serious offense, and is not permitted at the clinical facility sites by
students. Not calling or showing may be grounds for dismissal, and will be referred to the
Director of Nursing, Dean of Health & Human Services, and/or the Vice President of Student
Services. ALSO see APPENDIX Section 9.11 Policies Regarding Attendance form.
EXPECTATION OF THE STUDENTS
Because you have only two shifts in OB, you will not be giving any medications. Your
experience will focus on observation as well as practice of clinical skills. You will be assigned to
work with a staff nurse and will be expected to participate in caring for mothers and infants,
doing assessments, and practicing any skills that are within your scope of practice as student
LPNs. You are expected to arrange your nursing activities so you are on time for conferences.
Students are expected to come to pre and post conference ready to discuss and actively
participate. Information shared in pre and post conference regarding patients or fellow
classmates is considered confidential. “What is shared in the classroom stays in the classroom”.
NURSING CLINICAL POLICIES
Guidelines for Student Conduct: Students are expected to comply with student conduct policy
and procedures. Information on student responsibilities and rights is available at the following
websites: http://www.seattlecolleges.com/studentrules.aspx or
Intranet site: http://www.seattlecolleges.com/studentrules.aspx
Patient Confidentiality
Strict confidentiality should be maintained at all times. Refer to LPN Student Handbook.
Cell Phone Etiquette: To avoid disruption of the learning environment, students are expected
to turn off or silence cell phones. Phones are not to be on the student’s person. Do not answer
phone calls while on the unit. Please use scheduled breaks to return calls.
Classroom Diversity Statement: Respect for diversity is a core value of NSCC. Our college
community fosters an optimal learning climate and an environment of mutual respect. We, the
college community, recognize individual differences. Therefore, we are responsible for the
content and tone of our statements and are empathetic speakers and listeners.
Respectful and Inclusive Environment: The instructor and student share the responsibility to
foster a learning environment that is welcoming, supportive, and respectful of cultural and
individual differences. Open and respectful communication that allows for the expression of
varied opinions and multicultural perspectives encourages us to learn freely from each other.
Fragrance Policy: Students are requested to refrain from wearing heavily scented products
during class sessions, since some individuals may experience chemical sensitivities to fragrances
that interfere with their learning. Do not wear any scents, perfumes, strong smelling deodorants
or lotions.
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Transportation: Clinical instruction and experience are provided throughout the program in
long-term care facilities, acute care hospitals, and clinics. It is the student’s responsibility to
arrange transportation to and from these facilities.
Student Ratios: Clinical placements are made to ensure that all students receive the appropriate
variety of experiences. Long term care facilities and acute care facilities generally have a ratio of
6-8 students per instructor and clinics utilize the nurses as preceptors in a 1:1 ratio.
Dress Code: Students are to adhere to the standards, policies, and regulations of the clinical sites
during their clinical education program. These standards include wearing appropriate attire,
including nametags, and patches ironed on the left upper arm at the shoulder, and conforming to
the standards and practices of the site. Nametags and patches must remain visible at all times and
must not be covered by a sweater while on the floor. A sweater or T-shirt may be worn under the
scrubs. Students should wear casual business attire (no jeans) with facility ID badge during the
pediatric clinical if scrubs are not requested by your preceptor.
Facility Orientation: If the clinical site requires a special orientation of students, students
MUST attend or they will be unable to attend clinical. Each facility has unique policies,
procedures, and documentation practices. Students must attend the orientation in order to be
prepared to attend clinical and provide safe care for patients within these facilities. Students who
do not attend the orientation will meet with the Nursing Faculty and the Program Director, and
referred to the VP of Student Services.
Leaving the Unit: Students are to remain at the site during the clinical assignment. Leaving the
floor without notifying the staff and instructor/preceptor where patients are assigned is
considered abandonment of patients. If a student is found to have abandoned his/her patients, the
student may be referred to the VP of Student Services, which may lead to dismissal from the
program. If the student needs to leave the floor for any reason he/she must let the nurse in charge
and the instructor/preceptor know.
Standard Precautions: Students are expected to follow the Standard Precautions with ALL
patients regardless of whether they have a communicable disease or not.
Procedures and Treatments: Students should NOT perform any procedure/treatment
independently (i.e. giving meds, dressing changes, catheters, etc) without first obtaining
permission from the instructor/preceptor. Failure to do so may result in immediate dismissal for
the day followed by disciplinary action.
Clinical Errors: Clinical errors must be reported immediately to the charge nurse and the
clinical instructor. An NSCC Practical Nursing Program Student incident report must be filled
out, even if the instructor catches the error before the student administers the medicine or
treatment. In the event that the student does perform the wrong procedure a facility incident
report must also be made out. The student incident report will be placed in the student’s file until
graduation. Serious errors will be reviewed by the faculty and administration and may be
referred to the VP of Student Services. (See Student Clinical Incident Report in Section VII.)
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Injuries and Accidents: Any injuries sustained during the clinical day should be reported to the
nursing instructor immediately.
Student Support Services:
Students are encouraged to seek campus support services when necessary to support their
learning and academic progress. Refer to student handbook, brochures/flyers, or college website
for information about: Disability Services, Advising Center, Tutoring Services, Student
Leadership Programs, Library, Financial Aid Office, LOFT Writing Center Plus,
Admission/Registration/Records/Credentials (ARRC), Counseling, Women’s Center,
Multicultural Services Office, and/or Wellness Center
http://www.northseattle.edu/services/tutor/
INFORMATION FOR CLINICAL SITES
OB Clinical at Northwest Hospital:
Please meet instructors Margaret Johnston or Kristi Cunnington in the family waiting room
next to the nursing station of the Childbirth Center at 0630. Please arrive with your student ID
badge from Northwest Hospital. Your badge must be obtained from Security at Northwest
Hospital prior to beginning your clinical rotation.
NEO 114
Fall 2011
Childbirth Center Clinical Assignments
1)
Weekly Goals and Reflection Paper
Weekly Goals are to be completed and turned in at the beginning of each day of the clinical
rotation. Turn in your goal sheet at the beginning of the clinical day with your identified goals
and plan for meeting those goals. After you have completed the clinical day, take them home to
complete the evaluation portion. The completed goal worksheets should be typed and turned in
with your OB Care Plans. Your instructor may request that you submit them as an attachment to
an email or on ANGEL. Reflection papers should also be submitted with your OB Care Plans.
2)
OB Care Plans
There are three different types of OB Nursing Care Plans. You are expected to complete one of
the following Nursing Care Plans (NCPs), which includes both a maternal and neonatal
assessment: Labor and Delivery/Neonatal, Postpartum/Neonatal, or Antepartum (however,
if you use the antepartum NCP, you will also need to incorporate the neonatal assessment
section).One complete NCP is to be completed during the three shifts you will be in OB clinical
at Northwest Hospital. The NCPs should be turned in to your instructor’s mailbox by 5pm within
three days of your second clinical experience. However, your instructor may request that you
submit it as an attachment to an email or on ANGEL.
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NEO 114
Fall 2011
Pediatric Clinical Assignments
Pediatric Clinical Sites:
Students will attend a total of three days: two at a Group Health clinic and one at a child care
center. The clinical sites are:
1. Pinehurst Child Care Center
7330 35th Ave NE
Seattle, WA 98115
206-365-2197
Plan to arrive at 8am and stay until 3:30pm
Bring a lunch with you
2. Burien- Group Health Clinic
140 SW 146th St.
Burien, WA 98166
3. Factoria- Group Health Clinic
13451 SE 36th St.
Bellevue, WA 98006
4. Lynnwood (no Mondays) - Group Health Clinic
20200 54th Ave W.
Lynnwood, WA 98036
5. Northgate – Group Health Clinic
9800 4th Ave. NE
Seattle, WA 98115
6. North shore – Group Health Clinic
11913 NE 195th St.
Bothell, WA 98011
7. Redmond (no Mondays) – Group Health Clinic
15809 Bear Creek Pkwy Suite 100
Redmond, WA 98052
8. Renton- Group Health Clinic
275 Bronson Way NE
Renton, WA 98056
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Clinical Goals are to be completed and turned in the night before each clinical day by midnight,
electronically. Turn in your goal sheet with your identified goals and plan for meeting those
goals. After you have completed the clinical day complete the evaluation portion. The completed
goal worksheets should be typed and turned in by midnight one week after your clinical date. For
example, if you have clinical on Monday, your assignment will be turned in the following
Sunday by midnight (along with your reflection and assignment). If you have clinical on
Tuesday, then your assignment is due the following week on Monday by midnight, etc. PLEASE
LET ME KNOW IF THIS DOESN’T MAKE SENSE TO YOU SO I CAN CLARIFY.
As you interact with and observe the children attending the clinics and Pinehurst, you
will be able to apply what you learn in class to what you observe. Keys to your
assignment are your knowledge about child growth and development and stages of play.
Your assignment (along with goals and reflection) will be submitted to me electronically,
one (1) week after your last clinical day, in APA format, consisting of no more than 5
pages double spaced, using at least one outside source other than your textbook; citations
on the last page in APA format.
Well Child Observation (at Pinehurst Clinic), please address all of the following:
1. Observe at least 3 different child/adult interactions (parents dropping of their child,
various staff members). Briefly describe the individuals involved (age attire, affect,
comfort with the situation), and their interactions within the pair.
2. Assess the interactions observed in relation to theories of growth and development
(for example, Erikson, Piaget, Bowen, or Freud). Also assess how the child’s needs
are being met according to Maslow’s Hierarchy.
3. Comment on behaviors observed in terms of your own personal thoughts.
4. assess the environment in relation to child health and safety:
a. Are their restrooms with provisions for diaper change and disposal? Can children
reach the sinks?
b. Is food available for lunch and/or snacks? What kind of food? Is it suitable for the
for the age children you have observed? Why or why not?
c. What safety measures are there? Is their a first aid station?
d. What facilities are there for handicapped individuals? What is needed?
Feel free to add extra comments or observations.
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Sick Child Observation (at Group Health Clinics)
Please use the following points as a guide and address as many or as little as is possible.
When obtaining the Health History (bullet “I” below), address as many systems/questions
as possible for a complete history.
1. What are most of the children coming in for?
2. Who is accompanying the child? Both parents? Caregiver? Other siblings present?
3. How is the parental involvement? Are the parents anxious? How did this make you
feel as a student? How is/does the family cope/react to the child being ill?
4. Are there any socioeconomic, cultural, or religious factors that influence the child’s
health?
5. Did you notice various roles the nurse played? Family advocate? Health promoter?
Health teacher? Counselor?
6. Perform at least one Health History on a child to include:
a. Biographical data: name (watch HIPPA), address, telephone, parents name, date
and place of birth, gender, race, religion, nationality or culture background.
b. Chief complaint: why is the child here?
c. Current health or illness status: refers to the sequence of events that led to the chief
complaint and related information including – symptom analysis of chief complaint
(onset, timing, duration, character, severity, precipitating factors, associated
symptoms, and alleviating factors)
d. Other current or recurrent illness or problems
e. Current medications, vitamins, over the counter drugs, herbal remedies, and folk
remedies
f. Any other health concerns
g. Allergies
h. Past health: refers to problems and health promotion activities, including birth
history (pregnancy, labor and delivery, perinatal history), previous injury, illness,
or surgeries, allergies, immunization status, growth and development milestones,
habits.
i. Review of systems- ask about child’s overall health status, Health History
- integumentary system: ask about lesions, bruising, skin care habits, problems with
hair and nails
- head: ask about trauma and headaches
- eyes: ask about visual acuity, last eye exam, drainage, infections
- ears: ask about hearing acuity, last hearing exam, drainage and infections
- nose: ask about bleeding, congestion, discharge, and sinus infections
- mouth: lesions, soreness, tooth eruption, patterns of dental care, last dental exam
- throat: sore throats, hoarseness
- neck: stiffness, tenderness
- chest (respiratory system): ask about pain, cough, wheezing, shortness of breath,
asthma, infections
- cardiovascular system: history of murmurs, exercise tolerance, dizziness, congenital
defects
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j.
k.
l.
m.
n.
gastrointestinal system: ask about appetite, bowel habits, food intolerance, nausea,
vomiting, pain
genitourinary system: ask about urgency, frequency, discharge, urinary tract
infections,
musculoskeletal system: ask about pain, swelling, fractures, mobility problems,
scoliosis
Neurological system: seizures? Unusual movements?
Endocrine or metabolic system: ask about growth patterns
Psychiatric history: substance abuse? Eating disorders?
Family history: should include any family genetic traits or disease with familial
tendencies, communicable disease
Nutritional history: quantity and kind of food or formula ingested daily, problems
with feeding, use of vitamins and supplements, cultural or religious preferences
Sleep history: bed time habits, nap time
Psychosocial history: home and family function assessment (communication
patterns, family roles, pets, financial), school behavior (grades, peers), activity
assessment (activities, TV/computer time), discipline assessment ( type of discipline)
Obtain vital signs of patient: compare to normal vital sign ranges for age group you
are working with
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____________NORTH SEATTLE COMMUNITY COLLEGE_____________
NEO 114 DAILY CLINICAL PERSONAL/PROFESSIONAL GOALS
Personal/Professional Goals
How to Meet These Goals
Evaluation
(filled out prior to clinical; goals
should have specific clinical skill
focus)
(filled out prior to clinical)
(filled out after you’ve completed
your clinical)
Goal 1
Goal 2
Goal 3
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____________NORTH SEATTLE COMMUNITY COLLEGE_____________
DAILY REFLECTION: Complete after each clinical day and turn in with OB Nursing Care Plan.
Description of Clinical Experience
Reflection on Clinical Experience
(What happened in clinical today? Provide details)
(How did you feel about what happened today in
clinical? What did you learn, what did you already
know? What are your next steps?)
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North Seattle Community College
NEO 114
Labor and Delivery Nursing Care Plan
Student: ____________________________________________________________
Date: _________________
Date of Patient Admission: ___________________
PATIENT INFORMATION
Pt initials/identification:
Delivery date:
Time:
Age:
Type of delivery:
Gravida:
Para:
EBL:
Ab:
LC:
Complications of labor/del:
EDD:
Total length of labor:
Allergies:
Pain management in labor:
Maternal V.S.
Infant’s age at time of
exam:
Infant Sex:
Apgars:
Birth Weight: lbs./ gms
Feeding Method:
LABS AND DIAGNOSTIC TESTING (Include dates; indicate if abnormal value; discuss potential
implications if abnormal)
Rh and type:
Rubella:
HBsAG:
GBS:
HIV:
Antibody Screen:
Other: (STDs, Hep C, UA, etc)
Prenatal Labs:
Hgb:
Hct:
GDM Screening:
Other:
Ultrasounds:
Post Partum Labs:
Hct:
Hgb:
CBC:
MEDICATIONS (Include all medications during current hospitalization)
Name of Drug Dosage/Route/Frequency Indication
Generic &Trade
Other:
Effectiveness/
Side effects
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North Seattle Community College
Neo 114
Signs of labor prior to admission: (bloody show, SROM, U/Cs, mucous plug)
Discuss any prenatal diagnosis/es and implications (for both Cesarean and vaginal
deliveries):
Pain management: (non-pharmacologic comfort measures, narcotics, epidural/spinal)
Stages and phases of labor: (describe each in detail)
Fetal monitoring: (describe contractions, FHR baseline, variability, accelerations, deceleration, use NICHD
terminology; discuss interventions and rationale)
Care of neonate and rationale in delivery room and during recovery: (drying, tactile
stimulation, any resuscitation measures, vital signs, Apgars, medications, bonding, feeding)
Maternal care during recovery: (BUBBLE, vital signs, comfort measures)
Parent/infant attachment after delivery and during recovery:
Summary/other:
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North Seattle Community College
NEO 114
NURSING DIAGNOSIS/ PROBLEM LIST IN PRIORITY ORDER:
PRIORITY#____ (Identify by number and provide brief rationale for your decision)
Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms)
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


Assessments:
Interventions:
Outcomes:
Evaluations:
PRIORITY#____ (Identify by number and provide brief rationale for your decision)
Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms)




Assessments:
Interventions:
Outcomes:
Evaluations:
PRIORITY#____ (Identify by number and provide brief rationale for your decision)
Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms)




Assessments:
Interventions:
Outcomes:
Evaluations:
COMMENTS/HISTORY/REVIEW (Include a review of any significant medical history, prenatal diagnoses,
delivery complications, family adjustment, involvement of partner/father, support system, developmental phase of postpartum
family)
DISCHARGE NEEDS/PLAN: (Are there identified problems or barriers to discharge? What are the needs at home
after discharge? Resources? Discuss involvement of social work, home visits or referrals, developmental phase of family)
NAME:
North Seattle Community College
North Seattle Community College
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NEO 114
Post Partum Nursing Care Plan:
Student: ____________________________________________________________
Date: _________________ Date of Patient Admission:____________
PATIENT INFORMATION
Pt initials/identification:
Delivery date:
Time:
Age:
Type of delivery:
Gravida:
Para:
EBL:
Ab:
LC:
Complications of labor/del:
EDD:
Total length of labor:
Allergies:
Pain Management in labor:
Maternal V.S.
Infant’s age at time of
exam:
Infant Sex:
Apgars:
Birth Weight: lbs./ gms
Feeding Method:
LABS AND DIAGNOSTIC TESTING (Include dates; indicate if abnormal value; discuss potential
implications if abnormal)
Rh and type:
Rubella:
HBsAG:
GBS:
HIV:
Antibody Screen:
Other: : (STDs, Hep C, UA, etc)
Prenatal Labs:
Hgb:
Hct:
GDM Screening:
Other:
Ultrasounds:
Post Partum Labs:
Hct:
Hgb:
CBC:
MEDICATIONS (Include all medications during current hospitalization)
Name of Drug Dosage/Route/Frequency
Indication
Generic &Trade
North Seattle Community College
Other:
Effectiveness/
Side Effects
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NEO 114
SYSTEMS/MATERNAL ASSESSMENT
Cardiovascular: (include VS, heart rhythm, postruals prn, edema, pulses, Homan’s sign, activity tolerance, hx c/v
problems, HTN)
Respiratory: (RR, breath sounds, O2 sats, cough, Hx asthma, smoking in household?)
Neurologic:
(Pain Status, Sleep/Rest Patterns; also consider communication barriers, sensory deficits)
Breastfeeding: (include nipples, breasts, colostrum/milk, knowledge & preparation, past experience or concerns,
your
observations, lactation interventions)
GI : (include wt. or BMI, wt gain through pregnancy. bowel sounds, diet progression and appetite, hx eating disorders,
dietary restrictions?, last BM, hemorrhoids, usual bowel habits)
GU: (include fundus, lochia amount and character, I&O prn, ability to void after anesthesia/birth, dysuria, discharge, pp
diuresis)
Integument: (include hygiene, perineum, incision, IVs, rashes)
Endocrine: (consider thyroid, diabetes, hx infertility)
Psychosocial/Cultural: (include bonding, parent-infant attachment, role adaptations, family interaction, emotional
state & perceptions, cultural/religious practices/traditions, language barriers, alternative or complimentary health practices,
home environment, support, resources):
Infant Care: (participation in newborn care, assess learning needs, bonding, challenges)
Other:
North Seattle Community College
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NEO114
NEONATAL ASSESSMENT
Skin: (color, acrocyanosis, turgor, mucous membranes, jaundice, mottling, rashes, lanugo, vernix, Mongolian spots,
birth marks, echymosis, lesions)
Head/Neck: (symmetry,
caput, cephalohematoma, lesions, echymosis, types/ description of fontanels)
Eyes/Ears/Nose/Mouth/Face: (symmetry, position, abnormalities, epicanthal folds, sclera, drainage,
edema, ear pinna, nasal patency, palate, mucous membranes, tongue)
Chest/Lungs: (RR, bilateral breath sounds, grunting/retracting, nasal flaring, rales, rhonchi, nipple buds,
clavicle, symmetry)
Cardiac: (heart rate and rhythm, murmurs, color changes, peripheral pulses, cap refill)
Abdomen: (shape, tone, umbilical cord, bowel tones, palpation)
Genitals: (uretheral opening, penis, scrotal rugue, testes, labia majora, pseudo menses)
Extremities: (ROM, equal size, length, gluteal folds, symmetry, digits, webbing, color, cap refill, palmar &
plantar creases, reflexes)
Back: (spine curvature, sacral dimple, anal patency)
Neurologic: (all reflexes, deficits, hips)
Behavioral State: (feeding cues, crying, visual)
Feeding/ Elimination: (breast, bottle, frequency, suck, latch, Lactation Consult; void, anal patency, stool,
frequency)
Attachment/Bonding: (maternal, family, bonding, skin-to-skin)
Labs/tests: List all labs during hospitalization or labs
you anticipate prior to discharge (bilirubin, glucose, CBC,
hematocrit, Rh, hearing screen: include dates, normal or abnormal value, if abnormal discuss implications)
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NEONATAL MEDICATIONS (Include all medications during current hospitalization)
Name of Drug Dosage/Route/Frequency
Indication
Effectiveness/
Generic &Trade
Side Effects
NURSING DIAGNOSIS/ PROBLEM LIST IN PRIORITY ORDER (INCLUDES
MOTHER/INFANT DYAD):
PRIORITY#____ (Identify by number and provide brief rationale for your decision)
Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms)
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

Assessments:
Interventions:
Outcomes:
Evaluations:
PRIORITY#____ (Identify by number and provide brief rationale for your decision)
Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms)




Assessments:
Interventions:
Outcomes:
Evaluations:
PRIORITY#____ (Identify by number and provide brief rationale for your decision)
Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms)




Assessments:
Interventions:
Outcomes:
Evaluations:
COMMENTS/HISTORY/REVIEW (Include a review of any significant medical history, prenatal diagnoses,
delivery complications, family adjustment, involvement of partner/father, support system, developmental phase of family)
DISCHARGE NEEDS/PLAN: (Are there identified problems or barriers to discharge? What are the needs at home
after discharge? Resources? Discuss involvement of social work, home visits or referrals)
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North Seattle Community College
NEO 114
Antepartum Nursing Care Plan:
Student: ____________________________________________________________
Date: _________________
Date of Patient Admission:_______________
PATIENT INFORMATION
Pt initials/identification:
Age:
Gravida:
Para:
Ab:
LC:
Allergies:
EDD:
Current Gestational Age:
Birth Plan:
Anticipated Feeding Method:
V.S.
LABS AND DIAGNOSTIC TESTING (Include dates; indicate if abnormal values, implications)
Rh and type:
Hct:
Rubella:
Hgb:
HBsAG:
GDM Screening:
GBS:
HIV:
Ultrasounds:
Antibody Screen:
Other:
MEDICATIONS (Include all medications during current hospitalization)
Name of Drug Dosage/Route/Frequency
Indication
Generic &Trade
Effectiveness/
Side effects
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North Seattle Community College
NEO 114
SYSTEMS/MATERNAL ASSESSMENT
Cardiovascular:(include VS, heart rhythm, postruals prn, edema, pulses, Homan’s sign, activity tolerance hx c/v
problems, HTN)
Respiratory: (RR, breath sounds,O2 sats, ?cough, Hx asthma, smoking in household?)
Neurologic: Pain Status, Sleep/Rest Patterns (also consider communication barriers, sensory deficits)
GI: (include wt. or BMI, wt gain through pregnancy, bowel sounds, appetite, hx eating disorders, dietary
restrictions?, last BM, hemorrhoids, usual bowel habits)
GU: (include bleeding, bladder, dysuria, discharge)
Integument: (include hygiene, perineum, IVs, rashes)
Endocrine: (consider thyroid, diabetes, hx.infertility)
Psychosocial/Cultural: (role adaptations, family interaction, emotional state & perceptions, cultural/religious
practices/traditions, language barriers, alternative or complimentary health practices, home environment, support,
resources):
Other:
22
North Seattle Community College
NEO 114
1. Describe past medical/obstetrical history and prenatal diagnoses that may have
contributed to present risk factors for antepartum hospitalization.
2. What interventions have taken place? Also provide rationale for each intervention.
3. What information did you gain by reviewing the fetal monitor? (Use NICHD
terminology for baseline, variability, acceleration, decelerations). If early gestation, ultrasound monitor may not be used for
FHTs, describe the uterine contraction pattern.
4. Review implications of lab work, ultrasound reports, and/or any other diagnostic
modalities for this client.
5. What teaching needs does this client have and how would you present this information to
her?
6. Summarize the care you gave to this client during her hospitalization.
23
North Seattle Community College
NEO 114
NURSING DIAGNOSIS/ PROBLEM LIST IN PRIORITY ORDER:
PRIORITY#____ (Identify by number and provide brief rationale for your decision)
Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms)




Assessments:
Interventions:
Outcomes:
Evaluations:
PRIORITY#____ (Identify by number and provide brief rationale for your decision)
Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms)




Assessments:
Interventions:
Outcomes:
Evaluations:
PRIORITY#____ (Identify by number and provide brief rationale for your decision)
Nursing Diagnosis: (Identify problem, etiology & defining characteristics (signs & symptoms)




Assessments:
Interventions:
Outcomes:
Evaluations:
COMMENTS/HISTORY/REVIEW (Include a review of any significant medical history, prenatal diagnoses,
family adjustment, involvement of partner/father, support system, developmental phase of family)
DISCHARGE NEEDS/PLAN: (Are there identified problems or barriers to discharge? What are the needs at home
after discharge? Resources? Discuss involvement of social work, home visits or referrals)
CLINICAL EVALUATION OF STUDENTS
24
1. Clinical Evaluation Grading is based on the attached form with the point scale of 1-4 for
each category each clinical day.
a. Each student receives a formal, written clinical performance evaluation from the
instructor. The written clinical evaluation measures the student’s performance of
the course objectives, outlines strengths and weakness, and makes appropriate
recommendations for improvement if necessary. Students in danger of failing will
receive a Learning Agreement, which remains in the student file until graduation
from the program. (See Section VII for the Learning Agreement)
b. The student must sign the evaluation to show that he/she has read the evaluation.
If the student does not agree with the instructor’s evaluation he/she may make
comments on the document. A copy will be given to the student. (See Clinical
Evaluation Objectives/Clinical Evaluation in Appendix)
c. Clinical performance will be evaluated on a daily basis. If the student is deemed
unsafe, a Learning Agreement will be issued and the student will plan for
improvement with the instructor. If the safety issue continues, the student will
meet with the faculty and administration to discuss the student’s ability to
progress in the program. Performance evaluations will be written by the
instructor, reviewed by the student, and MUST be signed as evidence of having
been read. The student will receive a copy. Students may write a response to
instructor’s anecdotal notes.
25
EDUCATIONAL OBJECTIVES
Educational Objective: To develop a basic level of understanding and communication for
different obstetrical patients
Definitions: Mastery = student is able to complete a skill with minimal cueing from the
instructor.
Competency = student is able to complete skill with some cueing (no more
than 1-2 reminders) from the instructor
Student needs > 2 reminders from the instructor
Student is unable to perform skill or unable to perform skills at mastery
level with mastery requirement (skills designated with *)
The student demonstrates
1. Application of the nursing process in skills demonstrations:
a. Verbalizes necessary assessment prior to skill
b. Verbalizes the goal and /or rationale for the skill
c. Accurately identifies the client and introduces self
d. Implements the plan of care by performing the skill with proficiency
e. Evaluating the outcome of care plan
f. Modifying the plan of care to reflect the diverse needs of the client
g. Reports outcomes and findings to the appropriate person
h. Documents care given according to standards
2. Ability to organize client care and self by:
a. Completing all care within allotted time
b. Establishing appropriate priorities for care
c. Conserving supplies
3. Ability to adapt to change by:
a. Adapting to new clinical scenarios
b. Adapting care for individual client needs
c. Responding in a positive way to constructive criticism
4. Professional and therapeutic communication skills by:
a. Using correct medical terminology in all verbal and written communication
b. Demonstrating legible handwriting, correct spelling and grammar in all written
work
c. Protecting client confidentiality at all times
d. Demonstrating the ability to interact professionally with peers and instructors
e. Demonstrating the ability to interact with diverse populations
26
5. * Demonstrate application of microbiological principles by:
a. Following infection control procedures
b. Hand washing
c. Using surgical and medical asepsis correctly
d. Following standard and transmission based precautions
e. Following disinfection and cleaning techniques
f. Safely collecting specimens for testing
6. Demonstrates knowledge of NANDA Nursing Diagnoses
7. Demonstrates knowledge of and ability to obtain a thorough physical assessment in the
clinical setting
8. Demonstrates knowledge and understanding of a variety of medications, the medication
classification, what symptoms or disorders each medication is commonly used to treat, the
intended medication effect, common and serious side effects and contraindications.
9. Demonstrates knowledge of the Nursing Process in planning the care of clients from
diverse cultures while in the labor and delivery and postpartum clinical setting.
10. Demonstrates knowledge of the Nursing Process in formulating appropriate discharge
goals/discharge plans for labor and delivery and postpartum clients in the clinical setting.
27
NEO114: FAMILY NURSING CLINICAL
OB CLINICAL EVALUATION SUMMARY
STUDENT ____________________
INSTRUCTOR __________________
LOCATION _ NWHMC __________
DATES: FROM _______ TO _______
ABSENCES ____________
TARDIES
_________
Clinical Day:
1 2 AVERAGE:
CLIENT CARE:
SAFETY
INFECTION CONTROL & UNIVERSAL PRECAUTIONS
PREPARATION
SKILLS APPLICATION
PRIORITIZATION& ORGANIZATION
NURSING PROCESS:
HEALTH ASSESSMENT
PROBLEM IDENTIFICATION & NURSING DIAGNOSIS
PLANNING &IMPLEMENTATION
RELATING INFORMATION
EVALUATION & FOLLOW-UP
DOCUMENTATION:
DOCUMENTATION OF PATIENT DATA & CARE
ASSIGNMENTS & CLINICAL DAILY SHEETS
COMMUNICATION:
COMMUNICATION SKILLS
FEEDBACK
PROFESSIONAL BEHAVIOR:
PROFESSIONAL BEHAVIOR
& RESPONSIBILITY
TOTAL POINTS: _____
53-60= MEETS EXPECTATIONS CONSISTENTLY WITHOUT PROMPTS/REMINDERS
45-52= MEETS EXPECTATIONS CONSISTENTLY WITH PROMPTS/REMINDERS
37-44= MEETS EXPECTATIONS INCONSISTENTLY WITH PROMPTS/REMINDERS
<37 = DOES NOT MEET EXPECTATIONS <77% (FAIL)
28
______________NORTH SEATTLE COMMUNITY COLLEGE___________________
NEO 114: CLINICAL EVALUATION OBJECTIVES
EVALUATION
OBJECTIVES
I. CLIENT CARE:
SAFETY
INFECTION CONTROL &
UNIVERSAL
PRECAUTIONS
PREPARATION
DESCRIPTION
Demonstrate safe patient care within the childbirth center and
pediatric setting
Maintain a safe environment for self and patients.
(Examples: side rails up, bed low & locked, transfers, fall
prevention, patient identification, rights of medication
administration, disposal of sharps)
Demonstrate understanding of infection control and universal
precautions in delivery of patient care within the childbirth center
and pediatric setting
Adheres to infection control precautions. Applies appropriate PPE
for care and procedures. Demonstrates competency in use of
aseptic & sterile technique for care and procedures. Disposal of
waste in accordance to facility policy and procedure.
Demonstrate initial understanding of data gathering within the
childbirth center and pediatric setting
Research patient diagnoses, medications, treatments, labs. Review
medical record for patient history, labs, medications and physician
orders. Review skills manual and/or facility policy and procedure
prior to treatments and procedures. Review physician order and
gather supplies for treatments and procedures.
SKILLS APPLICATION
Demonstrate competency in skills within the childbirth center and
pediatric setting
Demonstrate competency in skills learned in NUR 117 & NUR
118. Performs skills and procedures with attention to patient
safety.
PRIORITIZATION &
ORGANIZATION OF
CARE
Demonstrate prioritization & organization of care for assigned
patients within the childbirth center and pediatric setting
Plan care for the shift; Adjust plan of care as needed; Prioritize
tasks and care for assigned patients; Seek assistance as needed.
Complete care and documentation for assigned patients in timely
manner. Collaborate with members of the health care team to
meet patient needs.
Demonstrate initial understanding of health assessment including
newborn, pediatric, labor & delivery, postpartum and parenting
patient population
Complete head to toe physical assessment of assigned patients.
HEALTH ASSESSMENT
29
Collect patient history data from medical record and/or patient.
Perform psychosocial assessment. Review lab work and
diagnostic test results. Compare assessment findings to patient
baseline.
PROBLEM
IDENTIFICATION &
NURSING DIAGNOSIS
Demonstrate initial understanding of problem identification for
the newborn, pediatric, labor & delivery, postpartum and
parenting patient population
Identify significant patient problems and provide nursing care that
reflects an understanding of those problems. Identify at least two
significant nursing diagnoses for assigned patients. Write
NANDA nursing diagnoses in correct format.
PLANNING &
IMPLEMENTATION
Demonstrates initial understanding of planning and
implementation of care for the newborn, pediatric, labor &
delivery, postpartum and parenting patient population
Reviews plan of care and implements interventions and basic
nursing care to assist assigned patients in meeting outcomes.
RELATING
INFORMATION
Demonstrate use of quantitative reasoning processes to
understand, analyze, interpret and solve problems for the
newborn, pediatric, labor & delivery, postpartum and parenting
patient population
Access, evaluate and apply information from a variety of sources
and a variety of contexts. Identify significant and relevant
assessment findings and relate these to the plan of care and
implementation of interventions.
EVALUATION &
FOLLOW-UP
Demonstrate initial understanding of evaluation of patient health
status and response to interventions for the newborn, pediatric,
labor & delivery, postpartum and parenting patient population
Identify and follow up with abnormal physical assessment
findings. Identify and follow up with abnormal vital signs, lab
and/or diagnostic test results. Evaluate and follow up with patient
response to treatments and interventions.
II. DOCUMENTATION
DOCUMENTATION OF
PATIENT DATA & CARE
Demonstrate initial understanding of documentation within the
childbirth center and pediatric setting
Document holistic care of the newborn, pediatric, labor &
delivery, postpartum and parenting patient population within the
scope of the practical nurse. Document relevant patient
assessment data, nursing care, medications and treatments
objectively and accurately in patient charts (paper and/or
electronic). Document data in timely manner and according to
30
CLINICAL DAILY
SHEETS &
ASSIGNMENTS
III. COMMUNICATION
COMMUNICATION
SKILLS
FEEDBACK
IV. PROFESSIONAL
BEHAVIOR
& RESPONSIBILITY
facility policy and procedure.
Demonstrate daily clinical sheets accurately
Assignments and clinical daily sheets are completed according to
instructions and turned in to instructor on due date. Assignments
and clinical daily sheets are detailed and thorough showing
evidence of understanding the patient condition, medications,
treatments, labs and nursing care)
Demonstrate effective communication with patients and the health
care team
Reports changes in patient health status, abnormal vital signs, lab
values and assessment findings to nurse preceptor and clinical
instructor in a timely manner.
Use effective interpersonal communication skills with patients,
families and members of the health care team.
Provide education to patients, families and members of the health
care team with focus on health promotion.
Identify patients’ health beliefs, knowledge level, and learning
styles and incorporate these into the provision of education.
Deal constructively with information, ideas, and emotions
associated with such issues of diversity and conflict as culture,
ethnicity, race, gender, religion, age, sexual orientation and
abilities.
Seek, accept and utilize feedback to improve professional
behavior and skills.
Respond positively to staff and/or instructor feedback and exhibit
recommended behaviors.
 Response to feedback is positive & part of recommended
behaviors exhibited (-1 point)
 Response to feedback is negative & part of recommended
behaviors exhibited (negative compliance) (-2 points)
 Response to feedback is positive or negative but
recommended behaviors not exhibited (zero points)
 Response to feedback is hostile or aggressive behavior is
exhibited (zero points)
Demonstrate and exhibit professional behavior in the learning
environment
Adhere to established policies of the NSCC nursing program and
of the clinical facility. (EX: Dress code; Confidentiality (HIPPA);
Attendance & punctuality; Professional behavior; Student
responsibilities & limitations). Accept responsibility for own
actions and behaviors. Holistically care for self, others, and
community within an ethical, legal and diverse framework within
the scope of practice of the LPN.
31
____NORTH SEATTLE COMMUNITY COLLEGE_________________________
NOE 114 EVALUATION TOOL SCORING
Directions:
Each of the clinical objectives is scored on each clinical day using
the following point scale*
4- Student meets expectations (objectives) consistently by performing previously learned
tasks and providing client care with no prompting or reminders and performing newly
learned tasks and client care with 1 reminder or prompting given throughout the shift.
3- Student meets expectations (objective) consistently by performing previously learned
tasks and providing client care with no prompting or reminders and performing newly
learned tasks and client care with 2 occasional reminders or prompting given throughout
the shift.
2- Student meets expectations (objectives) inconsistently by performing previously and
newly learned tasks and client care with 3 reminders or prompting given throughout the
shift.
1- Student does not meet expectations (Objective). Student is unable to perform previously
or newly learned tasks and provide client care unless provided with more than 3
reminders and/or step-by-step instruction from instructor.
N/A- No opportunity to observe
*Note: Partial points (ie. 0.5 or 0.25) may be given.
Any score of <2 requires a separate anecdotal note to be written and placed with the
student’s evaluation. The instructor should meet with the student to discuss the anecdotal
note & inform the student of inconsistency in meeting the clinical objectives. The clinical
expectations and objectives should be reinforced and the student assisted in forming a plan to
meet those objectives.
If during any clinical day or week the student receives a total of <37 points, the student may
be dismissed immediately from the clinical rotation. This indicates that the student is not safe
in the clinical setting.
32
CLINICAL EVALUATION OF SITE AND INSTRUCTOR
1. The following forms will be given to the clinical groups in the classroom at the end of the
quarter.
a. CLINICAL SITE EVALUATION
Students are expected to evaluate the clinical sites after their rotation. Classroom
instructors will administer these evaluations. See form in Appendix.
b. CLINICAL INSTRUCTOR/PRECEPTOR EVALUATION
Students are expected to evaluate the clinical instructors/preceptors after their
rotation. Classroom instructors will administer these evaluations.
NORTH SEATTLE COMMUNITY COLLEGE
33
NEO 114 CLINICAL EVALUATION
This is the OB evaluation for NEO 114 (50%)
CLINICAL GRADE: ______________________
________________________________
INSTRUCTOR SIGNATURE
________________
DATE
(Signature indicates that you have reviewed this document with the student and provided an
opportunity for the student to read the document and ask questions)
________________________________
STUDENT SIGNATURE
________________
DATE
(Signature indicates that you have read this document and been offered the opportunity to ask
questions)
COMMENTS
34
NORTH SEATTLE COMMUNITY COLLEGE
NEO 114 Pediatric CLINICAL EVALUATION
This is the final evaluation for NEO 114.
CLINICAL GRADE OB (50%): ______________________
CLINICAL GRADE Pediatric (50%):___________________
Final Grade:______________
________________________________
INSTRUCTOR SIGNATURE
________________
DATE
(Signature indicates that you have reviewed this document with the student and provided an
opportunity for the student to read the document and ask questions)
________________________________
STUDENT SIGNATURE
________________
DATE
(Signature indicates that you have read this document and been offered the opportunity to ask
questions)
COMMENTS: