CONCEPT MAP/CLINICAL PREP
(COMPLETE THIS AND PROVIDE REPORT TO CLINICAL FACULTY BY 0730.)
Student Name:
Date:
Date(s) of Care for the Assigned Patient:
Past medical history or previous medical diagnoses:
Patient Age:
Gender:
Religion:
Occupation:
Code Status:
SAFETY categories
S-Identify specific focused
assessment data to be
collected:
What should you focus your
assessment on and why?
A-Accuracy of
orders/assignments
F-What to do first?
What should you
delegate?
Allergies?
T-Trending data
Vitals ordered how
often?
Special measures:
Diet ordered for the
patient:
Safety precautions?
E-Expected
outcomes
Procedures ordered,
time & why:
Special measures
before and after:
What is the
expected
outcome with the
patient?
What considerations
should be
considered?
What should you
evaluate?
Y-Ethics,
family
concerns?
Miscellaneous
Oxygen Therapy
ordered?
What should you
monitor?
Any abnormal?
Labs due or
ordered for today?
1.
2.
3.
Why the patient
is ordered O2?
IV therapy? What is
the purpose for it?
Isolation precautions? Why is the
patient ordered?
What might you
anticipate?
11
ADOPTED FROM TOWSON UNIVERSITY
Any safety issues:
Due morning of clinical
Current Medications: (by 0745 with report to clinical faculty) List ALL regularly scheduled and PRN medications scheduled on your patient.
Cite reference and include page number from required Towson University DON Drug reference or textbook (due with final submission one week later, no internet
web sites accepted).
Generic/Trade Name
Dosage/Route
Classification
Be specific
Intended Action/
therapeutic use.
WHY is the patient
taking med?
Adverse Action/
1 major Side Effects
(May be verbalized)
Nursing Implications—1
appropriate for your patient
taking the ordered medication.
(May be verbalized)
Please clarify with your clinical faculty the PRN medications. Know the ones that your patient is currently receiving.
List any PRN’s given within the last 24 hours only.
12
8/2014 JMc
Daily Journal
Name:
Unit Assignment:
Date/Week:
Objective for the day:
Objective met:
yes
no (Why or Why not)
Summary of experience (Please include what you learned from today’s clinical experience.)
Most challenging patient situation:
Biggest challenge overall:
Your impressions & reactions:
New skills learned (list):
Skills reinforced (list):
Rank the day: (worst)
1 2 3 4 5 6 7 8 9 10
(best) please discuss with faculty if below 7 after clinical
8/2014 JMc
13
Clinical Performance Tool
Name:
Faculty:
Date/Week:
Students are responsible for each behavior listed on these outcome statements. A student who received a “U” in any area below must satisfactorily
remediate the area listed before the last day of clinical. This means a scheduled appointment with your clinical instructor or lab faculty. If the student
does not have a successful remediation, the student will not be permitted to go to the clinical institution for the remainder of clinical and may fail the
course. Any student who receives a “U” for two clinical days may fail the course.
RATING*
S U N/O
N/I N/A
I. ROLE: PROVIDER OF CARE
1.
2.
3.
4.
5.
6.
7.
COMMENTS
S N/I U
Is prepared for clinical assignment as assigned by clinical faculty (arrives on time)
a. Submits appropriate data (maps) for client assignment to clinical faculty on time.
b. Prepared for clinical skills necessary to safely perform assigned skills.
Verbalizes scientific rationale supporting nursing interventions for assigned skills.
Demonstrates therapeutic communication skills at a beginning level.
Demonstrates beginning skill in the application of nursing interventions.
Provides safe care with assigned skills and client interactions.
Begins to provide individualized client teaching during clinical as assigned.
Begins to evaluate effectiveness of nursing interventions in the achievement of patient outcomes.
II. ROLE: MANAGEMENT OF CARE
1.
2.
3.
Begins to prioritize nursing care appropriately.
Is organized. Care is complete at the end of the daily experience.
Demonstrates legal and ethical behavior that reflect accountability and standards of nursing practice
according to the ANA CODE OF ETHICS and NSNA standards.
III. ROLE: MEMBER WITHIN PROFESSION OF NURSING
1.
2.
3.
4.
5.
Demonstrates professional behavior when interacting with clients, families, and/or health care team
members.
Functions within the boundaries of the student nurse (including dress code).
Identifies own strengths and weaknesses in the clinical setting and seeks appropriate assistance from
faculty, staff and peers as appropriate.
Begins to recognize the importance of utilizing evidence-based literature to support clinical decision
making.
Prepares and participates in planning and discussion of assigned topics for post-conference.
Faculty Signature:
8/2014 JMc
*S=Satisfactory
Student Signature:
U=Unsatisfactory
N/O=Not Observed
N/I=Needs Improvement
N/A=Not Applicable
14
Daily Clinical Medication Administration Evaluation
Name:
Faculty:
Date/Week:
Students are responsible for each behavior listed on these outcome statements.
A “U” may lead to a CI-Clinical incident and failure of the day or course. Any area listed with N/I or U must be remediated as designated by the clinical
faculty member.
RATING*
S U N/O
N/I N/A
ASSESSMENT
1.
2.
3.
COMMENTS
S N/I U
Utilized assessment data regarding clients medication profile for safe outcomes.
Chose appropriate use of assessment data for each client for scheduled and unscheduled
medications.
Complete pain assessment when appropriate and prior to administering medications.
PLANNING
1.
2.
3.
4.
Demonstrated appropriate drug knowledge and nursing implications prior to administering meds.
Validated medication orders for clients prior to administering.
Communicated discrepancies and/or inappropriate dosages, as well as need to withhold
medications appropriately.
Communicated appropriately to instructor, staff, peers, clients, and significant others as needed.
INTERVENTION
1.
2.
[ ]
[ ]
3.
4.
5.
Demonstrated 6 rights during medication experience with faculty member.
Demonstrated safe knowledge regarding administration of medication by the following routes:
PO
[ ] IM
[ ] Insulin-SC [ ] SC
[ ] NG/G tube [ ] R [ ] Nasal
MDIs
[ ] SVN
[ ] Eye drops [ ] Ear drops [ ] Topical
[ ] IVPbk
Utilized safe and appropriate technique at all times.
Documented appropriately all meds given or not given.
Demonstrated responsibility for administration of scheduled and unscheduled medications,
including narcotic drugs according to agency policy.
EVALUATION
1.
2.
3.
4.
Evaluated effect of medications appropriately.
Evaluated self accurately and appropriately.
Sought assistance as needed from faculty member.
Demonstrates professionalism and accountability for performing and communicating
appropriately during medication administration.
According to Towson policies, agency policy and ANA code of ethics.
Faculty Signature:
8/2014 JMc
*S=Satisfactory
Student Signature:
U=Unsatisfactory
N/O=Not Observed
N/I=Needs Improvement
N/A=Not Applicable
15
What lab work is anticipated for the client and
why?
List and explain the abnormals ONLY.
What complications can occur? Be prepared to
discuss.
What medications will you give with the
main condition?
What measures should the nurse
consider before administering?
(Example: Check BP prior to giving, Hold
of BP < 90 systolic) etc.
Identify 1 priority NANDA dx related to admission dx.
What is the most “critical problem
Problem
Etiology
Sign/Symptom
(actual or potential problem)
List 1 projected outcome
List 3 interventions for
NANDA admission dx
These are the MOST
important that relate to the
main NANDA. Prioritize using
higher level interventions.
(Assessments, Labs, Meds.
Etc.)
What category of the client
needs from NCLEX test plan
does this apply?
www.nscbn.org WHY?
Admission Diagnosis of the Client
Describe the major reason of the client’s admission and include
pathophysiology of the disease. (Use a med-surg textbook to find your
reference)
What nursing interventions can be
delegated to the UAP or nursing staff
related to the priority NANDA Dx?
List 2 that you can delegate that assist
the RN’s interventions with main Dx
Example:
1. Ovarian cancer- Ovarian cancer is a disease that affects the
ovaries of the female (Smith, 2014)
2. Pancreatitis3. Diabetes Mellitus
List dietary
considerations today
with the care of the
client?
“I don’t know”
What is any area of the client care or
assessment don’t you understand?
List any past medical history of the client. Be prepared to describe these to
clinical faculty
Describe the cultural, social and religious needs
of the client- what about the living
arrangements? What members of the
interdisciplinary team are involved?
Safety concerns?
Identify a NANDA Dx
related to either of these
two areas. This can be an
actual or potential
problem for the client. Be
specific. Explain why
List any previous surgeries and dates of
surgeries for the client. How is this relevant to
your clients condition today?
Example:
Hysterectomy- 1985
Varicose Veins Stripped- 1993
16
Admitting Diagnosis _________________________________________
NURSING DIAGNOSIS
NEED 4 prioritized
EXPECTED OUTCOMES
Need to be timed and measurable
Date _________________________________________
INTERVENTIONS
RATIONALE
EVALUATION
Met, partially met or Unmet
and any changes needed
17