NURS 165R
Medical Surgical Nursing 1 Theory
SPRING SEMESTER 2016
Instructors:
Professor Debi Ingraffia-Strong PhD(c), MSN, RN
Lisa Dunkelberg MSN, RN
Dr. Cindy Pitlock DNP, CNM, APRN
Revised January 2, 2016 DI-S
NURS 165: MEDICAL SURGICAL NURSING I THEORY
3 Credits: Theory
Prerequisite courses: Successful completion of first semester of nursing program.
Corequisite courses: NURS 166R, and NURS167 Must pass NURS 165R, NURS 166R and
NURS 167 to continue in the nursing program. This series of courses must be repeated if
the student is not successful with any of the three courses.
I. COURSE DESCRIPTION
Teaches students to safely perform intermediate nursing skills (therapeutic procedures) that are
encountered in the care of hospitalized adult patients with common alterations in body systems.
Emphasizes the critical elements of nursing procedures and the scientific rationale for
performing the procedures safely.
II. COURSE OBJECTIVES
A. Upon successful completion of the course the student will be able to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Integrate research findings for evidence based practice that leads to best practice
outcomes.
Utilize therapeutic communication skills when interacting with patients and their
families.
Identify a patient's unique responses to selected illnesses and disorders across their
lifespan.
Integrate cultural, family, environmental and developmental factors, which affect a
patient's responses to illness and disorders, in a nursing plan of care.
Prioritize interventions using Maslow's hierarchy of needs in the plan of care for pediatric
and adult patients responding to selected illnesses and disorders.
Manage the patient's care through collaboration with other healthcare professionals.
Communicate and document accurate information to other healthcare professionals.
Apply principles of patients' rights within the ethical/legal framework of nursing in a plan
of care.
Demonstrate development of critical thinking skills through the use of the nursing
process for specific illnesses/disorders.
Discuss nursing strategies that promote cost effective care.
Recognize accountability for identification of self-learning needs and professional
development.
Design a patient teaching guide for a specific illness that utilizes the principles of
teaching/learning.
Develop a discharge plan of care for a patient that anticipates a patient's continuing health
care needs and the available community resources.
B. Linkage of the course to nursing program educational outcomes
Revised January 2, 2016 DI-S
1.
2.
3.
4.
5.
III.
Student Learning Outcomes
Integrate knowledge derived from the bio/psycho/social sciences, humanities, and
nursing to achieve deliberative and competent decision-making that is grounded in
evidence-based practice to achieve best practice outcomes.
Utilize information literacy skills to integrate research findings that guide (or lead to) best
practice decisions.
Apply concepts of cultural awareness, cultural sensitivity and respect for persons when
working with diverse populations
Utilize the nursing process in a competent and caring manner to safely meet the
bio/psycho/social/cultural and spiritual needs of patients across the lifespan in a variety of
health care settings.
Provide care that reflects the ethical values of nursing within professional practice
standards and the legal parameters of the profession.
METHODS OF INSTRUCTION
Classroom: Lecture/cooperative learning, problem posing, case studies, concept
mapping
Learning Activities: designing a patient teaching guide, developing a clinical discharge
plan for a community resource referral based on a site visit and reporting on the medical
and nursing care of a perioperative patient.
Materials: Required reading, audiovisual materials, assigned exercises; supplementary
handouts, & course WNC online (canvas) enhanced for syllabus, assignments, email,
discussion, chat room and grades.
IV.
METHODS OF EVALUATION
Exam 1
Exam 2
Exam 3
Exam 4
Final Exam
ATI testing and remediation
Cumulative points from exams must total 399 - equal to 75% in
order for the additional points to count
14 weekly EAQ quizzes (14 quizzes, 10 points each – the lowest quiz
score will be dropped to total 130 possible points; must be present in
class to receive EAQ points).
Patient teaching guide (PTG) (25 points)
PTG presentation (25)
ATI Integrated
 Focus review topics/practice test/active learning scenarios
 specific point allocation follows
Perioperative case report
Discharge referral plan
Total Possible Points – Must attain at least 626 points in order to
attain a passing grade of C and progress in the nursing program.
Revised January 2, 2016 DI-S
100 points
100 points
100 points
100 points
100 points
35 points
535 possible points
130 points
50
25
50
50
840 Total points
Course Grading Policy: The overall course grade is calculated by totaling all of the
points earned from the exams and assignments. The points for the assignments will be
added for the final course grade after a total point score of 399 on the exams is achieved.
If the 399 points is not achieved on the examinations, only the points earned on the
exams will be used to determine the final grade. Please refer to the Nursing Program
Student Handbook for objective criteria for theory grading and the grade distribution in
nursing courses.
Total points for the course is 800. Students must have a cumulative score of at least 626 in
order to receive a passing grade of C (75%) and progress within the nursing program.
Students must receive a grade of C or better in NURS 165R and a pass grade in NURS
166R and 167 in order to progress in the program. If the student is unsuccessful in any of
these courses during the semester, all three courses must be repeated.
Evolve Adaptive Quizzing (EAQ):
Each week EAQ is assigned for student completion prior to class for credit. These
are quiz questions that are linked to the chapter required readings. Students must be
Students must be present in class to receive EAQ points, and if not completed
prior to class no credit will be awarded. Students must attain a mastery level of 2 or
a minimum of 40 questions attempted for quiz points to be credited. The lowest EAQ
score will be dropped.
The access code for EAQ is: Elsevier Adaptive Quizzing COURSE ID:
152009_dingraffiastrong_1002 INSTRUCTOR: Debi Ingraffiastrong
Withdrawal Policy: The last day to drop a course with a “W” is April 1, 2016 otherwise
the grade earned for the course will be recorded.
Examinations:
All exams are taken online in the WNC Computer lab (see course schedule for specific
dates/times). Exams will start at 8:00 am sharp. Please be prompt. Class follows so those
with accommodations and extra time allowed must schedule accordingly so that they are
available to attend class on time following testing. Students will have one week from the
time they receive their exam score to express concerns about an exam question or exam
score. They should notify the appropriate faculty (each instructor who wrote the exam
questions needing review) via e-mail. The faculty will schedule a time for test-review
with the student during office hours.

Any exam question, concern or debate regarding exam questions must be submitted
via email to the appropriate faculty in APA format and rationale referenced per APA
within one week of the exam for consideration.
Revised January 2, 2016 DI-S
Any students caught cheating on an exam, quiz, or assignment will receive a 0. No
exceptions. Refer to criteria for exam taking.
Assignments:
Total: 150 points; a minimum of 112 points (75%) for assignments must be earned to
pass course.
Assignment 1: a. Patient Teaching Guide (PTG), 25 points &
b. Demonstration/Presentation, 25 points—total 50 points
Assignment 2: Report: Perioperative case report—50 points
Assignment 2: Report: Discharge Referral Plan/Presentation—50 points
Written assignments are to be posted in WNC online by midnight on the date designated
by the instructor. Three points will be deducted for each school day assignments are
turned in/posted to WNC online (canvas) late, unless the instructor grants a waiver for
late work. If the late penalty surpasses 25%, a 0 for the assignment will be given.
Refer to the student handbook for policies on legibility, completion of written
assignments, and grading policies. APA format will be used for all references and
citations when requested by instructor.
Students are expected to abide by the WNC Code of Student Conduct in all of their
classes http://www.wnc.edu/policymanual/3-4-4.htm
Plagiarism is a particularly serious violation, as outlined in the WNC policy manual,
Academic Integrity section of code #3-4-5. It will not be tolerated!
Patient Teaching Guides are graded by the nursing faculty who observes the
presentation. Perioperative Case Reports and Discharge Referral Plans are graded by
your clinical instructor.
Written work submitted late: Three points will be deducted for each school day the
assignment is late unless prior arrangements have been made with the instructor.
ATI Resources & Integrated testing:
End of course: Medical/Surgical Part I Integrated test: A 60 question test that evaluates
the understanding of the musculoskeletal, cardiac, respiratory, endocrine, immune,
integumentary, GI, and GU systems.
The ATI Exam does count toward the students’ exam grade. Students must still pass all
regular course examinations with a minimum average of 75% or greater in order to pass
the course. ATI Course Practice Examinations provide the opportunity to develop
NCLEX Exam preparedness and review of course content.
Med/Surg focus tests of specific content are available throughout the semester with
remediation available for all questions. This is a study aid and student resource for
remediation of course content. Three are required for the student to complete for a total
of 25 points.
Active learning case scenarios (remediation) will be developed by the student which
incorporates four concepts identified as areas of needed learning within the ATI printout
following the proctored exam. These are due by 8am Monday 05/16/16. These may be
submitted online or as a hard copy.
Revised January 2, 2016 DI-S
ATI
Points allocated
Total
points
possible
25
Points
earned
Total points possible 25
3 Practice tests
Content specific
(targeted)
End of Course ATI test (applies towards exam grade)
> Level 1 – 0 pts
4 active learning case scenarios – 27 pts
27 (75%)
Level 1 – 8 pts
3 active learning case scenarios – 20 pts
28 (80%)
Level 2 – 20 pts
2 active learning case scenarios – 15 pts
35 (100%)
Level 3 – 30 pts
1 active learning case scenario – 5 pts
35 (100%)
WNC online (Canvas) Course Requirements
This course utilizes WNC online (Canvas) to provide handouts and communicate with
students. Students will need to have the skills necessary to use the internet and a basic
understanding of how to download and print documents from the internet. You should
also know how to use a word processor that will save in an .rtf or .doc or html format to
type and submit papers via the web. Tutorial link and frequently asked questions and
answers regarding this online platform are available at http://www.wnc.edu/wnconline/
Canvas technical support for faculty and student is available 24/7 by phone or text chat
(855-308-2493). Canvas help can be accessed by clicking on the help link at the top right
of the canvas home page.
V.
RESOURCES
Lewis, S., Heitkekmper, M.E., Dirksen, S., O’Brien, P.G., Bucher, L. (2014). Medicalsurgical nursing: Assessment and management of clinical problems (9th ed.) St.
Louis: Mosby. and the companion CD
Doenges, M. E., Moorhouse, M.F., Murr, A.C. (2013). Nurse’s Pocket Guide: Diagnoses,
Prioritized Interventions, and Rationales (13th ed.) Philadelphia: F.A. Davis
Company.
Gahart, B. & Nazareno, A. (2015). Intravenous Medications. (32rd ed.). St. Louis,
Mosby.
Halter, M. J. (2014). Foundations of Psychiatric Mental Health Nursing (2014). St.
Louis: Mosby
Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder, J. (2014) Pharmacology and
the Nursing Process (7th edition) St. Louis: Mosby
Revised January 2, 2016 DI-S
Manning L., & Zager, L (2014) Concepts Made Insanely Easy for Clinical Nursing!
Duluth, GA: ICAN Publishing
Disability Support Services
Any student needing to request accommodations for a specific disability, counseling
and/or testing support to please meet with the DSS coordinator (445-3275) at your
earliest convenience to ensure timely and appropriate accommodations. The DSS office
is located in Bristlecone building, Room 103.
VI.
NURSING FACULTY INFORMATION
Debi Ingraffia-Strong MSN, RN
Professor of Nursing
Deborah.Ingraffia@wnc.edu
Office:
Cedar 231
Office phone: 775-445-3334
Cell phone:
775-901-0612
Lisa Dunkelberg
Nursing Instructor
Lisa.dunkelberg@wnc.edu
Office:
Cedar 229
Office phone: 775-445-4409
Cell phone: 775-450-6865
Dr. Cindy Pitlock
Nursing Instructor
Cindy.pitlock@wnc.edu
Office:
Cedar
Office phone: 775
Cell phone: 775
Office hours are posted outside of office door and on the WNC website.
Always available by appointment in office or on-line!
Cell phone limitations: faculty may be contacted by cell phone during the hours of 6am to
8pm for emergency questions. Please use email for nonemergency communication.
Emails will be returned within 24 hours or the next school day.
VIII.
STUDENT RESPONSIBILITY
The student is responsible for knowing and following the policies and procedures of the
college and the nursing program that define appropriate student behavior in NURS 165.
The student is responsible for prompt communication with the instructor for any student
concern or information needed to be successful in NURS 165.
The student is responsible for acquiring the necessary technology skills needed to access
WNC online for unit objectives, assignments and handouts, testing and communicate
between the instructor and other students.
The student is encouraged to request accommodations for a specific disability. The
student needs to notify the instructor of appropriate accommodations. The student needs
to coordinate the accommodations with Susan Trist (the DSS coordinator: phone 4453275) located in Bristlecone, Room 103 as soon as possible to ensure timely and
appropriate accommodations.
Revised January 2, 2016 DI-S
WNC Attendance Policy:
Students are expected to attend all classes for which they have registered. An instructor may
fail any student when the student has an excessive number of absences as identified in the
course syllabus. In general, if a student misses a number of hours greater than the number of
units to be earned in the course, this may be considered excessive.
Student absences will be acknowledged by each faculty member to determine if there is
an ongoing problem. Absences will be dealt with on a one to one basis between the
student, the instructors and the Director of Allied Health.
Students must be present in class to receive EAQ points.
Classroom Community
It is important that each person that attends this class have all the opportunity possible to master
this content. Every member of this class has the right to participate freely in the class activities
without interruption or feeling insecure or insignificant. In order for this to occur, certain
classroom conduct is expected. To following outlines behaviors that are expected of the
students and instructors.
1. Each member of the community is important to that community as any other member.
2. Every member of the classroom community deserves the right to speak his or her own
thoughts as long as those thoughts do not intentionally hurt another.
3. No member of the community has the right to interfere in the exercise of another
member’s right to speak: when a member is speaking no one else should.
4. All members of the community are expected to attend class and become involved in the
topic of the day. The benefit of coming to class is in networking with your peers and
coming to a better understanding of the topics discussed. Your attendance at class
benefits all.
5. Because time is limited and much content is covered it is important that the class begin at
the appointed hour. Those who arrive late have the following responsibilities:
a. Enter classroom prepared to participate. Do not make noise emptying book bags
etc.
b. Take the first available seat near the door.
c. Ask nearest student for directions as quietly as possible
6. The only learning materials allowed in the classroom are those directly related to the
activities of the class. All other materials, cell phone, PDA’s newspapers, magazines
must be put away. Shut off all cell phones. No texting allowed during class times!
Computers are allowed to take lecture notes, however no other online activities (such as
Facebooking) is allowed during lecture!
7. Trust and respect are expected for everyone in the classroom. Talking with your
neighbor and making unnecessary noise will not be tolerated.
Revised January 2, 2016 DI-S
8.
Your syllabus can answer all your questions about exams and classroom lecture
schedule. We will not answer questions such as “What is on the exam?” We will cover
exam topics as appropriate. Listen carefully. Recording lecture content is allowed for
your use only. These recordings are not to be posted to any internet source.
9. Web conduct: This is web-enhanced course. Active participation on WNC online is
required. Please check WNC online daily for new postings, announcements, etc. WNC
online is an excellent tool to communicate with the instructor and other students. Please
be respectful and post questions and material that is related to the classroom activities.
Any negative comments not related to classroom topics should be communicated
elsewhere.
10. Examples of misconduct during testing follow. Any student engaging in such behavior
will be dismissed and receive a “0” grade for the quiz/exam.
 Being late!
 Using electronic communications equipment such as pagers, cellphones, iPod’s or
PDA’s
 Giving or receiving help during the quiz or examination or being suspected of
doing so
 Using prohibited aids, such as reference materials, websites, listening devices, or
recordings.
 Sharing information about the test and test questions with any unauthorized
person.
Revised January 2, 2016 DI-S
NURS 165 LECTURE SCHEDULE ~ Spring 2016
1st session
9:00-10:20
Week 1 Introduction
1/25/16 Patient Teaching
Discharge
Planning
Community-based
resources
Instructor Reading/Lewis
Week 2 Preoperative Care
2/1/16 Intraoperative care
Prof DI-S
Date
Mrs. D
Week 3 Exam 1
2/8/16 Computer room 8-9:30
Class begins at 10:30 promptly
Week 4
2/15/16
Mrs. D
Week 5 Inflammatory
2/22/16 Process
Chap. 1 & 4
ATI review
rapid response
pp. 13 & RN
Community
Health Nursing
chaps 3 & 7
Chap. 18, 19 &
20
ATI Unit 14
Handouts
Chap. 12 pp.
172-178
Dr. Pitlock Chap. 27
pp.504
Influenza
Chap. 28 pp.
521-533
Week 7 Cardiovascular
3/7/16 Care (Vascular
disorders, PVD,
etc.)
Prof DI-S
Revised January 2, 2016 DI-S
Instructor
Reading/Lewis
Prof DI-S
EAQ 1
Readings from IV
module week
Postoperative
Care
(OR Lab)
Hematology
Prof DI-S
EAQ 2
Chap. 18, 19 & 20
ATI Unit 14
EAQ 3
Chap. 30 &31
ATI pp. 442-466
Mrs. D
PRESIDENTS HOLIDAY
Week 6 Respiratory
2/29/16 (Lower respiratory
problems Pneumonia, TB)
Week 8 Exam 2
3/14/16 Computer room 8-9:30
Class begins at 10:30 promptly
2nd session
10:30-11:50
Fluid &
Electrolytes
Chap. 32 & 33
Chap. 34 pp.
730-746, 750752
ATI pp. 294296, 299-302,
322-330, 349367
Immune
Process
Mrs. D
EAQ 4
Chap 14
ATI pp. 935-952
pp.981-1082
review as pertinent
Respiratory
(Lower
respiratory
problems –
COPD, etc.)
Dr. Pitlock EAQ 5
Chap. 29 pp. 560601
Chap. 68 pp. 16541662
ATI pp. 215-292
Cardiovascular
Prof DI-S EAQ 6
Care (CAD, Htn
Chap. 35 pp. 766etc.)
769
Chap. 36 pp. 787790, 803-804
Chap 38
GI (Surgical
bowel, Post-op
bowel,
Resection, etc.)
Dr. Pitlock EAQ 7
Chap. 39
Chap. 40 pp. 886890, 896-902
Chap. 42 pp. 924955
SPRING BREAK (3-21-16 thru 3-27-16)
1st session
Date
Week 9 GI (Chole, Appy,
3/28/16 Pancreatitis,
Diverticulitis)
Week
10
4/4/16
Endocrine
(Diabetes)
Instructor Reading/Lewis
Dr. Pitlock Chap. 43
Chap. 44 pp
1030-1041
ATI pp. 510609
Dr.Pitlock Chap. 48
Chap. 49 pp.
1153-1175,
1179-1188
Week Exam 3
Computer room 8-9:30
11
4/11/16 Class begins at 10:30 promptly
Week Neuro
(PD, Seizures)
12
4/18/16
Mrs. D.
Chap. 59 pp.
1413-1428,
1432-1437
ATI pp. 26-90,
113-121, 155165
2nd session
GI (GERD,
PUD, Hiatal
hernia, etc.)
Endocrine
(Hypo/Hyperthyroid)
Dr. Pitlock EAQ 9
ATI pp. 844-855,
868-891, 912-926
EAQ 10
Handouts and
review
Neuro (CVA,
TIA)
Mrs. D.
EAQ 11
Chap. 56
Chap. 58 pp. 13881397, 1400-1411
Week
14
5/2/16
Exam 4
Computer room 8-9:30
Class begins at 10:30 promptly
MS
(Fractures,
surgical repair,
tx)
Week
15
5/9/16
MS (surgical
hip/knee/back)
Finals
Week
EAQ 8
Chapter 40,42,
43,44 as per prior
readings
Mrs. D.
MS
(Osteoarthritis,
Osteoporosis,
gout)
5/10/16 1:00-4:00pm
Mrs. D
Reading/Lewis
Metabolic
Syndrome
Concept Maps
Case Studies
Week ATI Integrated testing
Computer room 8-9:30
13
4/25/16 Class begins at 10:30 promptly
Prof DI-S
Instructor
Culturally
competent care
Holistic Care
Modalities
Discharge paper presentations (Cedar nursing lab)
Business-casual dress
Prof DI-S & Mrs. D.
Dr. Pitlock EAQ 12
Chap. 62, 63, 64
Chap. 65 pp. 15611569, 1576-1578
ATI Unit 10
Prof DI-S EAQ 13
Chap. 62, 63, 64
Chap. 65 pp. 15611569, 1576-1578
ATI Unit 10
Prof DI-S EAQ 14
Chap. 2,6,10
ATI pp. 2-8
Cumulative Final Exam May 16, 2016 8:00-10:00 Computer Lab
Revised January 2, 2016 DI-S
WESTERN NEVADA COLLEGE
NURS165—Medical Surgical Nursing I
Assignment: 50 points
Community-Based Resource Site Visit
For Referral Determined During Discharge Planning
Essential components of discharge planning include assessing the strengths and limitations of the
patient, the family or support person, and the environment; implementing and coordinating the
plan of care; considering individual, family, and community resources; and evaluating the
effectiveness of care (Potter, et al, 2013). As a nursing student, you will need to learn how to
ensure that referrals are made to agencies such as home healthcare or social services which
provide support and assistance during the patient’s recovery period when discharged from an
acute care facility.
Steps you will need to complete to select a community-based resource site to visit:
1. Select a patient who is being discharged by asking the case manager or a staff nurse.
2. Visit the patient and explain your assignment and collect appropriate data.
3. Review the resources that are available within a particular community for a patient with a
case manager at the hospital where you have your medical/surgical clinical rotation.
4. Identify the appropriate services available to the patient in his/her community.
5. Select an agency to visit which provides specific services for a health problem that the
patient has.
6. Contact the resource site and arrange a time to visit.
7. Visit the site and collect data to determine if the patient will receive the needed care.
Once you have made your visit, write a report following the grading rubric attached. Each topic
is worth 10 points and correct APA style is worth 10 points for a total of 50 points. A minimum
of 2 reputable references is required.
The assignment is due one week after completion of the site visit but no later than May 8, 2016
Submit as a word document or rich text format in the assignment drop box on WNC (canvas)
online by midnight on the assigned day. Three points will be deducted for each school day the
assignment is late unless prior arrangements have been made with the instructor.
Revised January 2, 2016 DI-S
Discharge Paper and Presentation Grading Rubric
Learning Outcomes
Critical Elements
1. Describes the
biographical data and
reason for hospitalization
for the selected patient
2. Discusses who
participated in the
development of the
discharge
plan of care
3. Explains patient’s
involvement in the
decision making and
concerns. Explains the
needed services to be
provided (reason for the
referral)
4. Identifies the
accessibility of the service
for the patient and if any
special arrangements need
to be made.
5. Describes the agency:
contact person, types of
services provided, client
population, eligibility
criteria, operating hours
and general overview of
fees required, access to an
interpreter & other
accommodations
6. Identifies desired
outcomes from services for
patient
7. Discusses first
impression of the quality
of the interview & the
services provided by
facility. Reflects on what
was learned from this
learning assignment
8. Presentation:
engagement,
business/casual dress,
professionalism
Uses correct APA style for
citing of references &
reference list (2 or more
references minimum).
10 points total
Nonperformance
Satisfactory
Proficient
Exceptional
Information correct.
Missing content
Correct information
clearly written in a
concise manner.
Missing content.
Correct information
clearly written in a
concise manner. All
areas completed.
3.75, 4
4.25, 4.5
4.75 5
Below
3.75*_________
3.75, 4
4.25, 4.5
4.75, 5
Below
3.75*_________
3.75, 4
4.25, 4.5
4.75, 5
Below
3.75*_________
3.75, 4
4.25, 4.5
4.75, 5
Below
3.75*_________
3.75, 4
4.25, 4.5
4.75, 5
Below
3.75*_________
3.75, 4
4.25, 4.5
4.75, 5
Below
3.75*_________
3.75, 4
4.25, 4.5
4.75, 5
Below
3.75*_________
3.75, 4
4.25, 4.5
4.75, 5
Information incorrect,
confusing,
disorganized,
incomplete
Below
3.75*_________
Revised January 2, 2016 DI-S
NURS 165/167
Peri-operative Case Report Rubric
Peri-operative Paper Data Form
Points
5
4
4
8
2
2
5
7
4
4
5
50
Follow a patient through the perioperative period and write a report using the following rubric. This is a paper – utilizing APA
format. Tables may be included to synthesize data.
Report must be typed in narrative form following outline below, cite and reference list per APA.
In one paragraph reflect on what you learned from this experience including communication, relationships, and teamwork
between the OR staff, physicians and ancillary personnel.
PATIENT GENERAL INFORMATION
1. gender
2. age
3. ethnicity
4. medical diagnosis
5. surgical procedure
6. any vision, hearing impairment, language barrier
7. any disabilities
8. allergies (note reaction)
PATHOPHYSIOLOGY AND CONTRIBUTING FACTORS
a.
Description of pathophysiology underlying patient’s medical diagnosis and indication for surgery.
b. Medical history related to diagnosis and/or contributing to risks (co-morbidities).
SPECIFIC PREOPERATIVE ORDERS AND PREPARATION
a.
Medications – include IV solutions
b. Diet
c.
Urinary status: voided prior to surgery_____catheterized in OR_____Indwelling catheter_____.
d. Pre-operative teaching
e.
Consent signed
INTRAOPERATIVE CARE
a.
Skin prep: agent and location
b. Time out
c.
Position during procedure and nursing considerations
d. Brief description of surgical procedure
List of the type of anesthetics used and adjunct drugs given; anticipated nursing interventions based upon the effects of
anesthesia and related drugs.
POSTOPERATIVE CARE FOR THIS TYPE OF PROCEDURE
a.
List of post-op physician orders
b. Specific measures for this patient:
airway_____, O2 l/min_____, positioning_____, dressings____,
active warming_____, pain control_____,
NG tubes_____, drains_____, immobilizer_____, other_____________________
IDENTIFY ANY COMPLICATIONS from the list below that occurred or may occur during the postoperative recovery and
explain the interventions employed by the staff (See Lewis test)
Tongue falling back_____, retained secretions_____, Atelectasis_____, Dyspnea_____, Apnea_____, Laryngospasm_____,
bronchospasm_____, hypoventilation_____, pulmonary edema_____, aspiration_____, hypotension_____,
hypertension_____, arrhythmias_____, emergence delirium_____, delayed awakening_____, hypothermia_____,
hyperthermia_____, pain location and scale_____, nausea_____, vomiting_____, bleeding_____, wound dehiscence_____,
wound evisceration_____, other______________________________________
VITAL SIGNS
Preoperative
B/P, P, R, Temp, O2 sat, Pain
Intraoperative
B/P, P, R, Temp, O2 sat, Pain
Postoperative
B/P, P, R, Temp, O2 sat, Pain
Patient transferred or when you leave
B/P, P, R, Temp, O2 sat, Pain
Appropriate For Patient:
Anticipated NANDA Nursing Diagnoses
List PCs
Total points possible
Comments:
Instructor:______________________________________________________________________
Revised January 2, 2016 DI-S
NURS 165/166 - Medical-Surgical Nursing I
Grading Rubric for Patient Teaching Demonstration
Written Teaching Plan and Patient Teaching Guide: 25 Points
1 Point
2 Points
3 Points
4 Points
5 Points
Teaching plan is somewhat
clear with key information
missing
Learner outcomes are not
complete and are somewhat
appropriate to the subject being
taught
Teaching plan is clear, concise
but key information is missing
Teaching plan is clear, concise,
creative and comprehensive
Learner outcome(s) are not
complete but are appropriate
to the subject being taught
Learner outcomes are
comprehensive and appropriate
to the subject being taught
Teaching strategy is
appropriate level but not the
best format for teaching the
subject.
Message is simple, somewhat
creative and enhanced with a
few photos and graphics
Written @ greater than 5-6
grade level
Resources included
Material referenced
Teaching strategy is
appropriate level and format
for the subject.
Teaching plan is disorganized,
unclear
Teaching plan is not clear and
is poorly organized
Learner outcomes
are incomplete, difficult to
understand and
inappropriate to the subject
being taught
Teaching strategy is not clear.
Learner outcomes are not
complete and are inappropriate
to the subject being taught
Teaching strategy and format
are inappropriate to the subject.
Teaching strategy is higher or
lower level and not the best
format for teaching the subject.
Message is complicated,
inconsistent and not enhanced
with photos or graphics
Poorly presented ; significantly
<or> appropriate grade level;
Lacks resources and references
Message is complicated and
inconsistent – enhanced with a
few photos
Written at either <or> 5-6
grade level; Lacking resources
and references
Message is simple, not
enhanced photos or graphics
Written @ greater than 5-6
grade level
Lacking either resources or
references
Message is simple yet creative
and enhanced with photos and
graphics
Written @
5-6 grade level
Resources included
Material referenced
Demonstration of Teaching Plan: 25 Points
1 Point
2 Points
3 Points
4 Points
Does not consider patient’s readiness to
learn, uses inappropriate words, phrases
and body language and does not
consider patient’s culture
Ineffectively discusses learning
outcomes with the patient at the
beginning of the presentation but does
not consider patient’s abilities, lifestyle
or resources
Uses inappropriate teaching strategies
that are not supported by the patient
teaching guide
Considers patient’s readiness to learn
but does not consistently use positive
words, phrases and body language.
Considers patient’s culture
Effectively discusses learning outcomes
with the patient at the beginning of the
presentation and considers < 1 of
patient’s abilities, lifestyle or resources
Determines patient’s readiness to learn,
uses positive words, somewhat unaware
of body language, considers patient’s
culture
Effectively discusses learning outcomes
with the patient at the beginning of the
presentation and considers patient’s
abilities but considers only 2 of
abilities, lifestyle or resources
Uses teaching strategies that reflect the
patient’s ability to learn and are
supported by written material within 7589% of the patient teaching guide
Teaching flows in a logical progression
with active learning and ongoing
feedback to the patient 75-89% of the
time
Teaching effectiveness is evaluated and
documented
with 75 – 89% accuracy
Teaching promotes some active
involvement by the learner
Determines patient readiness to learn,
uses positive words, phrases and body
language, considers patient’s culture
Teaching does not flow in a logical
progression with minimal active
learning and ongoing feedback to the
patient.
Teaching is poorly evaluated and
documented with
<70% accuracy
Teaching inhibits active involvement by
the learner
Uses teaching strategies that reflect the
patient’s ability to learn and are
supported by written material within <
74% of the patient teaching guide
Teaching flows in a logical progression
with active learning and ongoing
feedback to the patient
< 74% of the time
Teaching is evaluated and documented
with 70-74% accuracy.
Teaching promotes minimal active
involvement by the learner
Professionally presented: (1 point possible)
 WNC uniform worn
 Clear, complete, concise
Comments:
Revised January 2, 2016 DI-S
Effectively discusses learning outcomes
with the patient at the beginning of the
presentation to make sure they are
appropriate for the patient’s abilities,
lifestyle and resources
Uses teaching strategies that reflect the
patient’s ability to learn and are
supported by written material with 90100% of the patient teaching guide
Teaching flows in a logical progression
with active learning and ongoing
feedback to the patient 90-100% of the
time
Teaching effectiveness is evaluated and
documented with 90 – 100 % accuracy
Teaching promotes consistent, active
involvement by the learner