N345_ClinicSyllabus Revised 8.8.17

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LosAngelesHarborCollege

AssociateDegreeRegisteredNursingProgram

Nursing345NursingProcess&PracticeintheCareoftheAdultClientIII

ClinicalMaterials

Fall2017–Spring2018

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TableofContents

STUDENTLEARNING&COURSEOUTCOMES/COMPETENCIES...…………………..……….………....….3

CLINICALEVALUATION……………………………………………………….…………………………………….…...5

GENERALHOSPITALINFORMATIONANDCLINICALPERFORMANCSTANDARDS…………………………6

REQUIREDCLINICALPAPERWORK...……………………………………………………………….………………7

CLINICALRESTRICTIONSANDADDITIONALEXPECTATIONS………………………………………….8

STUDENTORIENTATIONASSIGNMENT…………………………………………………………………………..9

ASSIGNMENTSHEETANDCLINICALFOCUS……………………………………...………………...……...10

Findtheworksheets/datatablesbelowundertheirrespectivetitles:

CLINICALPREPSHEET

PATHOPHYSIOLOGYSHEET

MEDICATIONADMINISTRATIONWORKSHEET

NURSINGHISTORY&ASSESSMENT

NURSINGCAREPLANS

NURSINGCAREPLANGRADINGRUBRIC

REFERENCEHANDOUTS

WEEKLYCLINICALEVALUATIONTOOL(WCET)

WEEKLYCLINICALEVALUATIONTOOL(WCET)GRADINGRUBRIC

SBAR

SKILLRERRAL

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LosAngelesHarborCollegeAssociateDegreeRegisteredNurseProgram

Nursing345–ClinicalObjectives

CourseOverwiewThiscourseisdesignedtoemphasizethenurse’sresponsibilityincaringforpatientswhoareacutely/criticallyillwithavarietyofmultisystemproblems,withanemphasisontheoxygenationandfluid/electrolyteneeds.Thesettingschosenfortheclinicalexperiencearestep-down/telemetryandcriticalcareunits.StudentLearningOutcomes/Competencies(thirdlearnerlevel):Atthislevel,whichcomprisescoursesinthethirdandfourthsemestersofthenursingprogram,studentsareexpectedtocontinuetoapplyandadaptmedical-surgicalnursingconceptstopatientsacrossthelifespaninavarietyofacutecare-basedhealthcaresettings,modifyplansofcare,andmakedecisionsforpatientsinavarietyofdevelopmentalstagesonthebasisofgeneralguidelinesofprinciplesderivedfrompreviousexperiences;organizeandprioritizenursinginterventionswithsupervision;anduseappropriateresourcestoassistinsolvingpatientproblems.Thestudentcanadaptbasicskillstodifferentagegroupsanddevelopnewskillsapplyingguidelinesthatarebasedoncuesfromexperts.Theyattempttocorrelateandbuildonmedicalsurgicaltheoryandpractice.ProgramLearningOutcomesforlevelthreeare:

1. IncorporatethenursingprocessusingtheRoyAdaptationModelincaringforadultmedical-surgicalpatients.

2. Integrateprofessionalbehaviorsornursingpractice3. Demonstrateclinicaldecisionmakingthatisaccurateandsafe.4. Providesafe,patient-centeredcare5. Functioneffectivelywithinnursingandinter-professionalteamsutilizingeffective

communicationstrategies6. Incorporateevidence-basedpractices,whichsupportclinicalreasoning.7. Identifyareasforimprovementinqualityandsafetyofhealthcaresystems.8. Utilizetechnologytoresearchpatientinformation&communicatewithinter-professional

teams.

CourseOutcomes/Competencies:

Attheendofthiscourse,withappropriatestudyandpracticeintheclassroomandclinicalexperience,thefourthsemesterstudentnursewillbeabletoassess,analyzeandcontributetothesafemedicalandpsychosocialneedsofthecardiopulmonarypatientinthecardiac,emergencyorcriticalcaresetting.Thestudentwillfocusonthepatientasawholewhilemeetingnursingneedsinthephysiologicalmode,aswellastherapeuticandreferralneedsintheself-concept,rolefunctionandinterdependencemodes.RefertothelistofStudentLearningOutcomes(1-8)listedabovethatwillbeidentifiedandmatchedtoitrelatedcourseoutcomeattheendofeachcompetencyinparentheses.

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Thenursingstudentwillbeableto:1. Incorporateadvancedassessmentdatatoformulateplanofcareforacutely/criticallyill

patients.(1)2. IntegratesCodeofEthics,StandardsofPractice,andpoliciesofcollege,nursingprogramand

clinicalagencies(2)3. Advocatesforpatientsandfamilies(2)4. Integratecriticalthinkingabilitiesandtheevidence-basedpracticesintheclassroomandclinical

settingsinprovidingcaretothepatientwithcomplexandmulti-systemneeds.(3,6)5. AdherestoNPSGandothersafetyguidelines(4)6. Performsnursingskillssafely(4)7. Safelyintegrateinterventionstoincludeadvancedskills.(4)8. Implementpainmanagementinterventionsforacutely/criticallyillpatients(4)9. Createcaringinterventionsthatassistpatientsinmeetingtheirbio-psycho-socialneedsacross

thelifespanandinvariousdevelopmentalstages.(4)10. Synthesizeknowledgeofculturaldifferencesasitrelatestocaringfortheacutely/criticallyill

patientwithcomplexandmulti-systemneeds.(4)11. Assessanddevelopstrategiestomeettheeducationalneedsofpatientandfamily(4)12. Functionaspartofaninterdisciplinaryteamtodeliverpatient-centeredcareinthecurrent

acutecarehealthenvironment.(5)13. Explainsareasforimprovementincareofassignedpatientsinhealthcaresetting(7)14. Integrateinformationtechnologyintodataresearchandchartinganddocumentation(8)15. Evaluatevalidityandreliabilityofinformationobtainedfromweb-basedsources.(8)16. Maintainspatientconfidentialityandsecurityofallhealthrecord(8)17. Provideindividualizedcaretopatientsrequiringartificialairways,mechanicalventilation,EKG

monitoring,ABGmonitoring,hemodynamicmonitoring,conscioussedationmonitoring,chesttubes,pacemakers,andvasoactivemedications.(1,3,4)

18. Integratetherapeuticcommunicationconceptsanddemonstratetheabilitytoestablishtherapeuticcommunicationwithpatientsandtheinterdisciplinaryteam.(5,8)

a. UtilizeSBARinclinicalsetting.b. Incorporatedataforsafepatienthand-off.

19. Demonstratetheabilitytosafelyintegratetherapeuticinterventionsforthepatientwithcomplexandmulti-systemproblemstoincludepreviouslevelskillsand:(1,3,4,6)

a. Physicalassessmentsofcardiopulmonarysystem.b. Vasoactiveandintravenouspushmedications(withdirectRNsupervision).c. Advancedmedicationcalculation:mcg/kg/min;mcg/mind. Hemodynamicmonitoring(withdirectRNsupervision)e. Artificialairways/mechanicalventilation(withdirectRNsupervision)f. BasicEKGmonitoringandpacemakersg. Conscioussedationmonitoringh. ABGanalysisi. Chesttubesj. Tracheostomycarek. Cardioversion/Defibrillation/ACLSProtocols

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ClinicalEvaluation:

Weeklyclinicalevaluationperformancewillbegradedonthefollowingscale:Satisfactory:Clinicalperformancedemonstratescontinuedgrowthtowardscoursecompetencies.Behaviorsareconsistent,safe,andperformedatexpectedlearnerleveldescribedinthestudentcompetencybehaviordescriptorsforsatisfactoryperformance.NeedsImprovement:Behaviorsmanifestedhavepotentialforcausingharm.Studentrequiresexcessivepromptinganddirectiontoperformsafelyandatexpectedlearnerlevel.Unsatisfactory:Behaviorsperformedareunsafe.Omitsstudentbehaviorsrequiredtoachievecoursecompetencies.Studentbehaviorslackknowledgebaseandskillcompetenciesexpected(seeunsatisfactorybehaviordescriptors).

Eachclinicaldayisevaluatedaccordingtothecriteriaintheclinicalevaluationtool.Theformissubmittedtotheinstructorattheendoftheclinicalexperiencefortheweek.Documentingnursingbehaviorsbythestudentandtheclinicalinstructoronthetooleachweeksupportstheperformanceratings.Thestudentmustreceivea“Satisfactory”performanceratingforallcriteriaontheweeklyclinicalevaluationformforaminimumofseventy-fivepercent(61hours)oftheclinicaldaysofthecourse.Therefore,studentsattendingclinicsinvolving12hourshiftsmaynotreceivemorethanoneclinicaldayratingat“NeedsImprovementor“Unsatisfactory”andthosestudentsin8hourclinicsnomorethantwoclinicdaysratingat“NeedsImprovementor“Unsatisfactory”inanyoneofthecriticalbehaviorcriteria(notedbyan*).Numbersgreaterthanthesewillresultinfailureofthecourseregardlessofthetheorygrade.Thestudentmustreviewratingsof“NeedsImprovement:or“Unsatisfactory”ontheclinicalformanddiscussthebehaviorintheananecdotalrecordwithdocumentationofappropriateinterventionsforimprovement.

Note:Anystudentbehaviorthatputsapatientinjeopardy(including,butnotlimitedto,emotional,physical,environmentaljeopardy),hasthepotentialtocauseharm,resultsinactualharmorinjury,orthatislife-threatening,willresultinimmediateremovalofthestudentfromtheclinic.ThesemesterfacultyteamtogetherwiththeChairpersonoftheHealthSciencesDivisionwillreviewstudentbehaviors.Suchbehaviorswillresultinclinicalfailure,withdrawalfromthecoursewithagradeof"F"andpossiblesuspensionorexpulsionfromtheNursingProgram.

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Generalinformation

Clinicdays/times: AslistedinScheduleofclassesPreconference0615-0700in____________________________________PostconferenceTBAin________________________________________

Phonenumbers: LosAngelesHarborCollegeNursingDivision:(310)233-4262Instructor:N.Ortegaoffice:(310)233-4367cell:(310)961-7980

Hospitals: ProvidenceLittleCompanyofMary-Torrance4101TorranceBlvd,Torrance,CA90503(310)540-7676TorranceMemorialMedicalCenter3330LomitaBlvd,Torrance,CA90505310)325-9110

ClinicalDays:ClinicalassignmentsaremadeonWednesday.YoumayselectpatientsonWednesdayafternoon,after1400.Pleasebeawareofandcheckassignmentsofothercollegenursingstudentsontheunittowhichyouareassigned.Ifyouduplicateanassignment,youwillnotbeabletocareforthatpatient.**Itisyourresponsibilitytokeeptheassignmentsheetupdated.

Thefollowingclinicalguidelinesarepresentedtohelpyouachieveclinicalobjectivesandasatisfactoryevaluation:

1. ClinicalPrepYoumustbepreparedtocareforyourpatient(s).Preparedmeansthatyou

a. Knowthediagnosisandwhattypeofpatientproblemsyoumayanticipate.Thiswillbedemonstratedbothinwrittenformat(onclinicalformsprovided)andverballywiththeinstructorinyourownwords.Utilizeresourcesforyourresearch,butdonotprovidematerialstraightfromatextortheInternet.

b. Arepreparedtocareforyourpatientassignmentby0615andhaveallwrittenpreparationmaterialstosubmittotheinstructor(i.e.,pathophysiologydocumentation,planningworksheet,andmedicationsheet).Verbalreportisgiventotheinstructoratthistime.

c. Havereaduponallskillsandproceduresneededandcanexplainthemtheoreticallyandarereadytoperformthemwithsupervision.Youmaynothaveactuallyperformedtheprocedureonapatientbefore,butwiththetheoreticalknowledgebase,wecanteachyouthemanualskill.

d. Knowallmedications(whetheryougivethemornot),toincludepurpose,correctdosage,sideeffects,andnursingimplications.Youcannotgivemedicationswithoutthismedicationsheetcompleted.

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2. RequiredWrittenWorkYouarerequiredtosubmitaclinicalwrite-uponeachpatienteachweekontheclinicalformsprovided.Youareexpectedtothoroughlyassess,carefor,anddocumentonallpatientscaredfor,butneedonlyturninacompletewrite-uponone.

1. PathoResearch:1AdmittingDx,2.SecondaryDxorSurgicalorProcedure2. PrepPatientSpecific3. Mar

Theclinicalwrite-upincludesitems1-3plus:4. Historyandassessment(Summaryofineffectivebehaviors/stimuli/nursingdiagnoses

teaching/learningneeds)5. Onephysiological,psychosocial,andteachingcareplanbasedonprioritizationof

problems6. Weeklyclinicalevaluationtool

Allclinicalwrite-upsaredueonthe______________followingtheThursdayclinicaldayandatthetimeindicatedbyeachclinicalinstructor.CorrectedpaperworkwillbereturnedbythebeginningofthefollowingThursdayclinicalday.

3. MedicationAdministrationa. TheinstructormustbewithyouforallIM,subcutaneous,andIVPmedicationsaswell

asforallsterileprocedures.(Note–afterconfirmingstudentcompetency,thestudentmaygiveoralandsubcutaneousindependently.)

b. Theinstructormustcheckallmedicationsforallroutespriortomedicationadministration.

c. Allpatientsmusthaveanidentificationbraceletonpriortoadministeringmedicationsandpriortoinstructoraccompanyingstudentintoroom.

d. Allpertinentassessmentandlaboratorydatamustbeavailablepriortopreparingandadministeringallmedications.

e. AllmedicationsontheeMARmustbecheckedagainstthephysician’sorderseachmorning.

f. Ifaneworstatmedicationisordered,itmustbeobtainedfromthepharmacy.Itisthestudent’sresponsibilitytoadministerthemedicationwithintheappropriatetimeframe.

g. ALLinsulinandheparinmustbedouble-checkedbytwolicensedpersonsandthestudentandco-signedbytheRNorclinicalinstructor.

h. Youareresponsibleforregularlycheckingforneworders!

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4. ClinicalRestrictions:Certainlimitationsareimposedonstudentsinthecriticalcareareas:

a. Careofhemodynamicmonitoringequipmentcanonlybedoneunderthedirectsupervisionofthestafforinstructor.

b. Studentswillnotbeallowed,unlessspecificallydirectedbytheinstructorto:• Drawbloodfrominvasivelines• Performcardiacoutputmeasurements• Performdefibrillationorcardioversion• Careforpatientsonintra-aorticballoonpumps

5. UnsafeClinicalPerformance:TheDepartmentofHealthSciencesreservestherighttodismissastudentwhoseclinicalperformanceforanynursingcourseisdeemedunsafeascharacterizedbydangerous,inappropriate,irresponsibleorunethicalbehaviorthatactuallyorpotentiallyplacesthestudent,patient,patient’sfamily,orhealthteammembersinjeopardy.ThenursingstudentmustpracticewithintheboundariesoftheNursePracticeActofCalifornia,thecourse/clinicalobjectivesandguidelinesofNursing345,theLosAngelesHarborCollegeDepartmentofNursingpolicies,andthepoliciesandproceduresoftheclinicalfacilityassigned.Thestudent’sbehaviormustdemonstratecontinuityofcarethroughtheresponsiblepreparation,implementation,anddocumentationofthenursingcareofpatients.Inaddition,thestudent’sbehaviormustberespectfulofallindividuals(patient,patient’sfamily,healthteammembers,andself)accordingtotheAHAPatients’BillofRights,theANAStandardsofCare,theANACodeforNurses,andclinicalagencypolicies/procedures.Thestudentmaybesuspendedordismissedfromtheclinicalexperiencesatthediscretionofthefacultymemberandthefourthsemesterfacultyteam.

6. SIMLABAssignmentsStudentswillsignupforone6-hoursimulationexperiencetocompletetherequiredclinichours.Thesimulationexperiencewillhavethesameexpectationsofprofessionalbehaviorasanyotherclinicalday.Afailuretomeetthestandardsforclinicalcompetencewillresultinunsatisfactoryevaluationforthisexperience.

7. AbsencesIfyouareillandmustbeabsentfromaclinicalday,youmustcallyourassignedunitat0630andtheinstructorat0700.YoumustdoBOTH.Pleasealsobeawarethatforthisshort-termcourse,morethanoneclinicalabsenceisconsidered“excessive.”Theonlyreasonsforanexcusedabsenceareillnessormedicalemergency.Also,anabsenceMUSTbemadeupinanotherclinic,basedonspaceandinstructoravailability.

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LosAngelesHarborCollegeAssociateDegreeNursingProgram

StudentOrientationtoClinicalUnit

Itisthestudent’sresponsibility,foreachunitassigned,toorientthemselvestothenursingunit.Assignment-Locatethefollowing:

• studentassignmentsheetposted• Areawherereportisreceived–howisreportgiven?• ComputerizedCharts–locateandfamiliarizeselfwithformatofH&P,physicians’orders,

progressnotes,laboratorydata,radiologyandcardiopulmonaryreports,medicationrecords,clinicaldata,nursingandinterdisciplinaryplansofcareandnursingnotes,diagnoses,pastmedicalhistory,emergencycontacts,med/diet/activity/treatment/labdiagnostictestorders,anyotherpertinentinformationforpatient

• Telephones/computerterminalsforstudentuse• Medications–MAR,locationofpatientmedications(PyxisorOmnicell),suppliesformedication• administration(medcups,syringes,needlelesssupplies,alcoholwipes,medcrusher,flushesfor

salinelocksandcentrallines,IVadmixtures,IVPBmedications,“stock”medications• Centralsupplyroomand/orcart• IVsupplies–primary/secondary/specialtubing,labels,volumeinfusionpumps• Dietarysupplies–tubefeedingsandtubefeedingsupplies,patientfooditems• Linencart/closet• Patientshowers(telemetry),hygieneitems• Clean/DirtyUtilityrooms• Linenhampers• Oxygensupplies–flowmeter,nasalcannulas,masks,ambubags• Crashcart/defibrillator–lookthroughlistofsuppliescontainedoncarttofamiliarizeyourself

withcontents(DONOTREMOVELOCK)• Policy&Procedure/InfectionControl/IntravenousTherapymanuals• PDR/Micromedexreferencesonunit• Fireextinguisher,emergencyevacuationplan• Findanemptypatientroomandorientyourselftohowthebedworks,howtooperatebedrails,

callsystem,howtooperatelights,“CodeBlue”button(warning–DONOTTOUCH)

Completedon__________________Timespent____________________

PrintName___________________________________Sign_________________________________

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LOSANGELESHARBORCOLLEGEAssociateDegreeRegisteredNursingProgram

Nursing345–NursingProcess&PracticeintheCareoftheAdultClientIII

ASSIGNMENTSHEET4THSemesterRNStudents

STUDENT ROOM#(S) PATIENT(S)INITIALS

CLINICALFOCUS:

□ VS/PhysicalAssessment □ MedicationAdministration(PO,Topical,SQ,IM,IVP,IVPB)

□ EKGInterpretation □ IVF/TPNMonitoring□ ArtificialAirwayManagement □ Simple/ComplexDressingChanges□ CareofPatientonMechanicalVentilator □ EnteralFeedings□ HemodymamicMonitoring □ CentrallineManagement

ClinicalHours: Thursday 0615-0700(Preconference) 0700-1830(OnUnit) 1230-1330(LunchEducationalConference) 1830-1930(PostConference)Instructor: NobeybaJ.Ortega,RN,MSNACNS-BC(310)961-7980

ClinicalPrepWorksheet

Student: Date(s) of Care: Admit Date: Initials

Age/Gender: Room# Allergies:

CC: AdmitDiagnosis:

Surgery/Procedures:

History:

Activity:

Lines:ALPICCPACTLCCVPPIV

Tubes:FCOther:NG/GTCTJP

RespInterventions/O2:

IVFluids:

IVDrips: Diet/TubeFeeding:

FSBS:

DiagnosticTests:CXREKGECHOOther:

ABGs:pHPaCO2HCO3PaO2

O2sat%BE

Labs: Na CL BUN Glucose K+ CO2 Cr HgB WBC Platelets HcT

Medications 08 09 10 11 12 13 14 15 16 17 18 19 Treatments:Follow-Up:PlanofCare:

Los Angeles Harbor College Associate Degree Registered Nurse Program

Pathophysiology Preparation Sheet*

Medical Diagnosis: How would you define this diagnosis to your patient (brief): Etiology / Pathophysiology: Laboratory & Diagnostic tests – What abnormal would you expect and why? Anticipated Ineffective Behaviors (clinical manifestations): Collaborative Interventions (include rationale): Medical/Nursing: 1. 2. 3. 4. 5. 6. Top 3 (Actual or High Risk For) Nursing Diagnoses: 1. 2. 3. *Cite Sources:

MEDICATIONADMINISTRATIONWORKSHEETN345 Room#

Revised 2.1.16

Generic/TradeNameClassification/Dosage/Route

UsualDosage(Routes of

Administration)

MechanismofActionOnset/Peak/

Duration

SideEffects&AdverseEffects

NursingManagement(Implications&Teachings)

IndicationforUse/IndicationforThisPatient

Time

LosAngelesHarborCollege AssociateDegreeRegisteredNursingProgram

1

NURSINGHEALTHHISTORY&ASSESSMENTFORMMEDICAL-SURGICALADULTCLIENT

HighlightallineffectivebehaviorsStudent:_________________________________________ClinicalInstructor:_____________________________Client’sInitials:______Age:_______(Pleaseincludeprepsheet,pathophysiologysheets,andmedicationsheets.)GeneralAssessment:Cognitive/Sensation(Neurological)SubjectiveData*(Circleorfillinappropriateresponse)Painassessment:Pain:Rating___/10;Location_____________________Sensation/Mobility:______________________________Aching___ Burning__ Numb___ Piercing__ Pulling__ Sharp__ Shooting___Tingling___Stabbing___Throbbing___Dull___Other____________Duration:Ispainalwaysthere?Y/NDoesitcomeandgo?Y/NWhatmakesthepainbetter?_____________________Worse?______________________________________BehavioralPainScore(CPOT):________Sensation/mobility______________________________Abilitytocommunicate___________________________Does client have any physical, psychosocial or cognitivedevelopmental lags that aggravate his/her illness or inhibitself-care?Y/N__________________________

ObjectiveData*(Circleorfillinappropriateresponse)Generalappearance:Well-nourished/Thin/ObeseAwake&oriented:person/place/time/purpose:Y/NFollowsdirectionsconsistently:Y/N______________Affect:________________Position:________________Speechclear&appropriate:YN__________________Spontaneousmovement:UpperYNLowerYNUnresponsive:YNLethargic:YNAgitated:YNAphasic:YNConfused:YNForgetful:YNGlasgowComaScale(GCS)EyeOpening:__VerbalResponse:__MotorResponse:__Total:_____Pupils:Size:R____L____Equal:____Reacts:R___L___FollowsCommands:____________________________StrengthofExtremities:__________________________Appearance/SkinIntegrity:_______________________RASSScore:_______________(ifsedated)

CPOT–CriticalCarePainObservationToolIndicator Description Score

Facialexpression Nomusculartensionobserved Relaxed,neutral 0Presenceoffrowning,browlowering,orbittightening,andlevatorcontraction Tense 1Alloftheabovefacialmovementspluseyelidtightlyclosed Grimacing 2

Bodymovements Doesnotmoveatall(doesnotnecessarilymeanabsenceofpain) Absenceofmovement

0

Slow,cautiousmovements.Touchingorrubbingthepainsite,seekingattentionthroughmovements

Protection 1

Pullingtube,attemptingtositup,movinglimbs/thrashing,notfollowingcommands,strikingatstaff,tryingtoclimboutofbed

Restlessness 2

MuscletensionEvaluatedbypassiveflexionandextensionofupperextremities

Noresistancetopassivemovements Relaxed 0Resistancetopassivemovements Tense,rigid 1Strongresistancetopassivemovements,inabilitytocompletethem Verytenseorrigid 2

Compliancewiththeventilator(intubatedpatients)ORVocalization(extubatedpatients)

Alarmsnotactivated.Easyventilation Toleratingventilatorormovement

0

Alarmsstopspontaneously Coughingbuttolerating

1

Asynchrony;blockingventilation;alarmsfrequentlyactivated

Fightingventilator 2

Talkinginnormaltoneornosound

Talkinginnormaltoneornosound

0

Sighing,moaning Sighing,moaning 1Cryingout,sobbing Cryingout,sobbing 2


2

PhysiologicalMode:OxygenationNeeds[Pulmonary/Cardiovascular/PeripheralVascular]SubjectiveData*(PriorToAdmission)Smoking:N/YQuitDate:______NicotinePatch:N/YHx:____pk/yrsCough_____________________SputumProduction___________Dyspnea___________________Dizziness___________________Weakness__________________Swelling(PTA)________________Chestpain(PTA)______________Palpations__________________Bleeding/Bruising____________HxbloodtransfusionsY/NReaction(s)_________________

ObjectiveData*(Circleorfillinappropriateresponse)VitalSignsT:______HR:____RR:____BP:___/___SpO2_____Oxygenvia____@_____Pain______/10Qualities:__________________________________________HEART:ApicalPulse:Rate:_______Rhythm:________PMI:_____________________Strength:________Heartsounds:___________Murmurs:_______________EKGMonitorRhythm:_____________________________________________Pacemaker:Type:_____Rate:_____Mode:______%Pacing:____ICD:Y/NExtremities:JVD:________CapillaryRefillTime:_______Temp:___________Color____________Sensation:______________Movement:_____________PeripheralPulses:RUE:________LUE:________RLE:________LLE:_______PeripheralEdema:________________________________________________Pitting:________________________S/SxDVT:_____________________Treatment/PreventionDVT:__________LINES:LocationPICC:____________CVC:____________ArterialLine:____________PulmonaryArteryCatheter:___________@___cmLines:Zeroed/calibratedPAP:____/____PAMean:____CO:_____CI:_____SVR:_____CVP:____LUNGS:Respirations:regular/irregular/symmetrical/labored/unlabored/shortnessofbreath(SOB)atrest/dypneaonexertion(DOE)Breathsounds*:RUL:____________RML:____________RLL:____________

LUL:____________LLL:_____________*Key:Clear(C)Diminished(Dim)Absent(A)Crackles(Cr)Wheezes(W)Rhonchi(Rh)Cough:Y/N/productive/nonproductive.Sputumamount____________Consistency: liquefied/thick/bloodtinged/other__________________Color:clear/white/yellow/brown/green/gray/other:_____________Odor:_____Chesttube:Location:R/L/Upper/Lower/Posterior/AnteriorDrainage:DrainageSystem:______________Color:__________Tidaling:N/YDrsgIntact:N/YAirLeak:N/Y____________SQEmphysema:N/Y_______VENTILATORSETTINGS:ArtificialAirway:_________Size:_____Location:______________________Mode:______Rate(f):_____TidalVolume(Vt)(TV):_______FiO2:_______PEEP:______PressureSupport(PS):_______CPAP/BiPAP:_______________

Cardiovascular/PeripheralVascularLabWork&TestsHgb:_____Hct:_____WBC:_____Platelets:______PT:_____INR:_____PTT:_____Othercoagulationstudies:_________________BloodType:___Unitsordered:___given:___ConsentsignedN/YCardiacEnzymes:Troponin:____CPK:____CKMB____%____BNP:____Chol____Trig____HDL____LDL____ABGs:pH_____pCO2______pO2_____HCO3_____BE_____O2sat______FiO2______Temp:_______Cultures:Type:_____________________Results:______________________________MRSA:________________ChestX-ray:________________________LungScan:______________________CT/MRI:____________________Ultrasounds:_____________________________PulmonaryFunctionTest(PFT):___________________________EKG(12-lead):________________________________________ECHO:________________________EF%:_____StressTest:___________________________________Angiogram:______________________________________Other:________________________________________________________________________________________


3

PhysiologicalMode:FluidandElectrolytesNeedsSubjectiveData(PriorToAdmission)UsualIntake(PTA):___________UsualOutput(PTA):___________Likes/Dislikes:______________Weakness/Cramping:_________Meds/Supplements/Limits:

ObjectiveDataHeight:_______Weight:______(kg)FluidLimit_____________________24HrsI&O:Intake:______Output:______FluidBalance:+/-_______IVSite:______Type:____Size:___Patent:N/YFlushed:N/YCondition:________IVSite:______Type:____Size:___Patent:N/YFlushed:N/YCondition:________Solution:____________________________________@____mL/hr___gtt/minSolution:____________________________________@____mL/hr___gtt/minIVDrips:______________________________@____mL/hr_______________IVDrips:______________________________@____mL/hr_______________FluidChallenge:___________________________________________________HemodialysisaccessY/NSite:_____________________Bruit:N/YThrill:N/YPeritonealDialysisY/NDescribesite:________________________________NG/AbdTubes/AbdDrains:________________________________________

LabWork:ElectrolytesNa+____K+___Cl-____CO2____Mg+_____Ca++____Phos_____X-Ray______________________PhysiologicalMode:NutritionalNeeds:GastrointestinalSubjectiveData*(PriorToAdmission)UsualDiet/CulturalPreferences:_________________________________Likes:__________Dislikes:__________FoodAllergies:__________________Nausea:Y/NVomiting:Y/NGERD:Y/NDysphagia:Y/NChangeinAppetite:Y/NUsualWeight:_______Recentloss/gain+/-______Overwhattimeperiod________

ObjectivedataDiet:______________________________________________________Nutritionalsupplements:_____________________________________Gavageformula:_________________________________@____mL/hrvia________________tubePlacementconfirmed:Y/NResidual:_____Calories/24hrs:_________NutritionalImbalance:__________NutritionalRequirements:________Difficultychewing:Y/NSwallowing:Y/NDentures:Y/NAbdomenShape:soft/firm/flat/distended/tender/rigid/ascitesother_________BowelSounds:_____________________________TUBES:NG/OGLocation:_______________Suction:_________Clamped:N/YPEG/GT/JTLocation:____________Suction:________Clamped:N/Y

LabWork:Glucose:____TotProtein:____Alb:___LFTs:____________________________Amylase:______Lipase:____________Ammonia:______Lactate:__________SwallowingEvaluation:______________EGD______________________________AbdominalX-ray/CT/MRI___________PhysiologicalMode:EliminationNeeds:Genitourinary/GastrointestinalSubjectiveData*(PriorToAdmission)Voiding-Control:___________Urgency:____Frequency:____Dysuria:____Nocturia:___UseofMeds:____________________Defecation-Control:_____Frequency:_____UseofMeds:____________________

ObjectiveDataI&O:_______________Wt:___________+/-________Voids:N/YIncontinent:N/YColor:_______Quality:________Foley:N/YIfyes,whatisdocumentedneed?_________________Suprapubic:N/Y____UrinaryDiversion:N/Y__________________Other:_________________________________________________StoolColor:_____Amount:____Consistency:____LastBM:_____Incontinent:_____________________________________________Ileostomy/Colostomy:____________Stomaappearance:_______RectalTube/Pouch:_____________________________________GIdrains:______________________________________________

LabWork:BUN______Creatinine______GFR_______Uricacid____Urinalysis________________UrineCulture__________C.difficile______Colonoscopy__________________________


4

PhysiologicalMode:Rest&ActivityNeeds/Sleep/OrthopedicSubjectiveDataPain/Discomfort/Fatigue/Weakness_____________________________UsualSleepPattern:____________Meds/Rituals:_________________UsualActivity/Exercise:_________

ObjectiveDataActivityLevel:__________________________________HOB:___________Posture/Position:________________Motordeficits:__________________Functionallimitations:______________Paralysis/Amputation:__________Restraints/Casts/Traction/Restriction__________________________________ROM/PT/OT/ADL/Exercise_______________________________________Gait:Strength:______Steady/Unsteady/Shuffles/Shortsteps/NotambulatoryHrs.Slept/Disruptions:___________________________________________

LabWork:CPK(MM):_______SkeletalX-ray/EMGStudies_____SAFETY:RiskforFalls(Morse)–CircleappropriatenumberPreviousfall 25 Gait/TransferringNormal/Bedrest(0)

Weak(10)Impaired(20)1020

Secondarydiagnosis 15 MentalStatus:Orientedtoownability(0)ForgetsLimitations(15)

15AmbulatoryAid:Crutches(15)Furniture(30)

1530

IV/HeparinLock 20 TOTAL NoRisk0-24LowRisk25-50HighRisk≥51RESTRAINTS:MDorder_______Restrainttype__________Reason_________________________________________Circulation/MobilityAssessed____Q___H.ProvidedNutrition___Hydration___Elimination___Hygiene___Mobility___Q__HPhysiologicalMode:SensoryRegulationNeeds:Endocrine/Eyes/EarsSubjectiveDataSensoryChanges/Deficits:_________Aids:_____________Language:_______________ReadingDeficits:____________Fatigue/Heat-ColdIntolerance:_________________________Post-menopausal:N/Y;Ifyes,HRT:N/YIfnot,LMP:______

ObjectiveDataEyes:DrainageY/NTearingY/NVision(impaired):NY_____________________Hearing(altered)NY_______________________HearingAides:YN_________________________Taste(altered):NY_________________________Smell(altered):NY________________________Touch(altered):NY_______________________Hair(describe):____________________________

LabWorkTSH:___T3:___T4:___Thyroxine:______Cortisol:____SerumGlucose:_____HgbA1C:_________FBS:______

PhysiologicalMode:ProtectionNeeds:IntegumentarySubjectiveDataChangeintypicalskincolor/temp/conditionNY___________________Anyrecentchangewithincreaseofinfections(e.g.resp.,urinary)NY________________________________LabWorkWBC________SerumAlbumin_______C&S:____________________________

ObjectiveData(Specifylocations)Temperature:hot/warm/cool/coldTurgor______Intact_____Ecchymosis_________Jaundice:Y/NPetechiae______Denuded_____Rash/Irritation_______Lesions_____Incisions_______________________Dressingintact________________Steri-strips_____Staples______Sutures_______Drain(s)_____________Drainageorredness____________________________________________DermalulcersY/NLocation:_____________________________________Stage_____Size________Drainage:Y/NOdor:Y/NDescribe_____________________________________________________

Subjective:Riskforskinbreakdown(BradenScale)–CircleappropriatenumberSensoryperception Moisture Activity Mobility Nutrition Friction&ShearCompletelylimited1Verylimited2Slightlylimited3Noimpairment4

Constantlymoist1Verymoist2Occasionallymoist3Rarelymoist4

Bedfast1Chairfast2Walksoccasionally3Walksfrequently4

Completelyimmobile1Verylimited2Slightlylimited3Nolimitations4

Verypoor1Probinadequate2Adequate3Excellent4

Problem1Potentialproblem2Noapparentproblem3

Note:Patientswithtotalscoreof18orlessareconsideredtobeatriskfordevelopingpressureulcers.15-18=Mildrisk.13-14=Moderaterisk.10-12=Highrisk.9orbelow=Veryhighrisk.

RiskAssessmentTotal


5

Psychosocial:RoleFunction(Role-Relationship)Whatis/wasyouroccupation?_____________Other:___________Howmanyyearsinthatoccupation?_______Ifretired,howmanyyearsretired?______Doyouanticipatethatyourillnesswillhaveaneffectonyourabilitytowork?Y/NHobbies:___________________Ethnicity/culturalidentity:_________Religion:_________Maritalstatus:_________Children:___________Developmentalstagesoffamily

Marriedw/nochildrenActivechildbearingPre-schoolorschoolagechildrenAdolescentchildrenandleavinghomeMiddleagechildrennolongerlivingathomeElderly:wellfunctioningElderly:infirm

Withwhomdoyoulive?_______________Supportive?Y/NLivealone?_________Retirementfacility?________AssistedLiving?_________SkilledNursingFacility?___________Normalrolewithinfamily?_____________Doesshe/heanticipatearolechangeduetoillness?Y/N___________Anyindicationofproblemsin:Rolerelationship/socialisolation/ImpairedSocialInteraction?Y/N_____________Psychosocial:Self-Concept(observefacialexpressions/Bodyposture/toneofvoice)Physicalself

Selfperception:FeelingsofLoss:_______________________Isolation:______________________________Bodyimage:Change/Perception/Disgust/Insecurity/Isolation:___________________________________Howwouldyourateyourhealthonascaleof1to10______

AnxietyBehaviors:________________________________________________________________________PersonalSelf

SelfConsistency:Copingmechanisms:__________________________________________________________Strengths:___________________________________Weaknesses:_________________________________

Selfideal:Helplessness:__________________________Powerlessness:_______________________________Moral–EthicalSelf:Guilt:__________________Shame:_________________Spirituality_________________

Psychosocial:InterdependenceSupportSystem/SignificantOthers:_______________FinancialStatus:______________Insurance:_____________DependentBehavior:HelpSeeking:_________________AttentionSeeking:_________________AffectionSeeking:_________________InterdependentBehavior:Assistanceneededduetoconstraintsofillness/age/etc._______________________________________________IndependentBehavior:InitiativeTaking:____________ObstacleMastery:________________AbilityToCommunicate:________________Howoftendoyougoforprofessionalexams?(physical,dental,BP,etc)__________________________________________Alcohol/tobacco/substanceuse/abuse/othermaladaptivebehaviorstomanageproblems:_________________


6

Teaching/LearningNeeds/DischargePlanning1. Whathasthedoctortoldyouregardingyourhealth?_______________________________________________2. Doyouunderstandyourmedicaldiagnosis?Yes___No___3. Describethetreatmentsandmedicationsyouhavereceived:________________________________________

AnticipatedDateofDischarge:_________________

DischargeInstructions:(meds,diet,woundcare,whentocallMD,followupetc.)1. ResourcesAvailable:Persons(s):_________________Financial:_____________2. Doyouanticipatechangeinyourlivingsituationafterdischarge?Yes___No___3. Ifyes:areasthatmayrequirealteration/assistance:Medication/IVtherapyY/NWoundcareY/NFoodpreparation/DietY/NTransportationY/NShoppingY/NAmbulationY/NTreatmentsY/NSuppliesY/NSelf-careassistance(specify)_______________Y/NPhysicallayoutofhome(specify)_______________Y/NHomemakerassistance(specify)__________Y/NLivingfacilitiesotherthanhome(specify)___________Y/NUnderstandingdisease/WhentocalltheMD/Follow-upY/NOther_________________________________

DescribeDischargeinstructions:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Listspecificguidelinesforspecialdiets,e.g.Lowsodium,ADA,Renal:

Isyourpatient’sdietmeetingfoodpyramidguidelines:YNIfno,includespecificsastowhattoavoidandwhattoincludetoensureadequatenutrition:TEACHINGCAREPLAN

Behaviorsindicatingknowledge/skillsdeficit:________________________________________________________________________________________________________________________________________________________Neededself-careskills/knowledge:_________________________________________________________________________________________________________________________________________________________________OngoingTeachingPlans:_________________________________________________________________________________________________________________________________________________________________________BarrierstoLearning:___________________________________________________________________________________________________________________________________________________________________________EnhancingReadinessforLearning:________________________________________________________________________________________________________________________________________________________________PriorityTeachingCarePlan:1.______________________________________________


7

ForALLineffectivebehaviorsidentifiedinthehistoryandassessment,identifystimuliandpotentialnursingdiagnoses.Prioritizethetop3nursingdiagnosesinboththephysiologicalandpsychosocialmodes.BEHAVIORS STIMULI NURSINGDIAGNOSISOxygenationNeeds:

Fluid&ElectrolyteNeeds:

NutritionalNeeds:

EliminationNeeds:


8

BEHAVIORS STIMULI NURSINGDIAGNOSISActivity/SleepRestNeeds:

Sensory/RegulatoryNeeds:

ProtectionNeeds:Integumentary

PsychosocialMode:RoleFunction:Self-Concept:Interdependence:

PRIORITYNURSINGDIAGNOSESPhysiologicNursingDx:1._______________________2._________________________3.______________________PsychosocialNursingDx:1._______________________2.________________________3.______________________***Complete1physiologicalandonepsychosocialnursingcareplanbasedonprioritizationofproblems/nursingdiagnosis.

LOSANGELESHARBORCOLLEGEAssociateDegreeNursingProgram

STUDENTNAME:ClientInitials: NURSINGCOURSE:345 Client’sSecondaryRoles:

PrimaryRole:

NURSINGPROCESSNursingCarePlan

MaturationStage: TertiaryRoles:

DevelopmentalTasks:1.

2. 3. StageofIllness:

AssessmentFirstLevelBehaviors

AssessmentSecondLevel

Stimuli

NursingDiagnosis

GOALS/ExpectedOutcomes

THERAPEUTICNURSINGINTERVENTIONS(Nursingactivitiestoachieveoutcomes

andRationalesforinterventions)

EvaluationCheckOutcomes:

Yes?No?

SubjectiveData:

Asmanifestedby:

Goal(s):

ObjectiveData:

ExpectedoutcomesAsevidenceby:

LOSANGELESHARBORCOLLEGEAssociateDegreeNursingProgram

STUDENTNAME:Clientinitials: NURSINGCOURSE:345 Client’sSecondaryRoles:

PrimaryRole:

NURSINGPROCESSTeachingCarePlan

MaturationStage: TertiaryRoles:

DevelopmentalTasks:1.

2. 3. StageofIllness:

AssessmentFirstLevelBehaviors

NursingDiagnosis

GOALS/ExpectedOutcomes

THERAPEUTICNURSINGINTERVENTIONS(Nursingactivitiestoachieveoutcomes

andRationalesforinterventions)

EvaluationCheckOutcomes:

Yes?No?

SubjectiveData:ObjectiveData:

Asmanifestedby:

Goal(s):

ExpectedoutcomesAsevidenceby:

Nursing345GradingCriteria

DATABASESubjective/ObjectiveDataonHistory/Assessment

HighlightIneffectiveBehaviors

30

OrganizationofIneffectiveBehaviorsintoModes,includingStimuliandNursingDiagnoses

20

PrioritizationofNursingDiagnoses 5TOTALFORDATABASE 55

TEACHINGCAREPLANTeachingPlanDataBase 3IneffectiveBehaviorsSubjective/Objective

3

NursingDiagnosisProblemsupportedbyatleast3ineffectivebehaviors

2

OutcomesMeasurable,realistic,clientspecific,withacriticaltime

2

NursingInterventionstoeliminateorreducebarrierstoeducation/teachingorenhancereadinesstolearning

4

Evaluation 1TOTALFORTEACHINGCAREPLAN 15

NURSINGCAREPLANSClientProfile 1

IneffectiveBehaviorsSubjective/Objective

3

Stimuli 2NursingDiagnosis

Problem/Etiologysupportedbyatleast3ineffectivebehaviors2

OutcomesMeasurable,realistic,client-specific,withacriticaltime

2

NursingInterventionstoeliminateorreducestimuliwithrationale

4

Evaluation 1TOTALFORNURSINGCAREPLANS 15X2=30

GrandTotal=100%(100POINTS)Passing=75%(75points)

• BothNCPsmustbe75%(11.5/15points)• OnephysiologicandonepsychosocialCP• Musthave2setsofpassingNCPstopassclinical• MayonlyuseaspecificnursingdiagnosisONCE.

NANDA NURSING DIAGNOSIS Last updated August 2009, *=new diagnosis 2009-2011 Activity/Rest-ability to engage in necessary/desired activities of life (work and leisure) and to obtain adequate sleep/rest • Activity intolerance • Activity intolerance, risk for • Disuse syndrome, risk for • Divisional activity, deficit • Fatigue • Insomnia • Mobility: bed, impaired • Mobility: physical, impaired • Mobility: wheelchair, impaired • Sedentary lifestyle • Sleep deprivation • *Sleep pattern disturbed • Sleep, readiness for enhanced • Transfer ability, impaired • Walking, impaired Circulation- ability to transport oxygen and nutrients necessary to meet cellular needs • *Bleeding, risk for • Cardiac output, decreased • *Tissue perfusion, decreased cardiac

tissue, risk for • *Tissue perfusion, ineffective,

cerebral, risk for • *Tissue perfusion, ineffective, renal,

risk for • *Tissue perfusion, ineffective

gastrointestinal, risk for • Tissue perfusion, ineffective,

peripheral • *Shock, risk for Ego Integrity- ability to develop and use skills and behaviors to integrate and manage life experiences • Anxiety • Anxiety, death • Body image, disturbed • Coping, community, ineffective • Coping, community, readiness for

enhanced • Coping, defensive • Coping, family, compromised • Coping, family, disabled • Coping, family, readiness for enhanced • Coping, (individual), readiness for

enhanced • Coping, ineffective • Denial, ineffective • Energy field disturbance • Fear • Grieving • Grieving, complicated • Grieving, risk for complicated • Health behavior, risk prone • Human dignity, risk for compromised

• Personal identity, disturbed • Post trauma syndrome • Post trauma syndrome, risk for • Power, readiness for enhanced • Powerlessness • Powerlessness, risk for • Rape-trauma syndrome • Relocation stress syndrome • Relocation stress syndrome, risk for • *Resilience, impaired individual • *Resilience, readiness for enhanced • *Resilience, risk for compromised • Self concept, readiness for enhanced • Self-esteem, chronic low • Self-esteem, situational low • Self-esteem, risk for situational low • Sorrow, chronic • Stress, overload Endo • Blood glucose, risk for unstable Elimination- ability to excrete waste products • Bowel incontinence • Constipation • Constipation, risk for • Constipation, perceived • Diarrhoea • *Motility, dysfunctional

gastrointestinal • *Motility, risk for dysfunctional

gastrointestinal • Urinary elimination, readiness for

enhanced • Urinary elimination, impaired • Urinary incontinence, functional • Urinary incontinence, overflow • Urinary incontinence, reflex • Urinary incontinence, stress • Urinary incontinence, urge • Urinary incontinence, risk for urge • Urinary retention Food/fluid- ability to maintain intake of and utilize nutrients and liquids to meet physiological needs • Breastfeeding, effective • Breastfeeding, ineffective • Breastfeeding, interrupted • *Electrolyte imbalance, risk for • Failure to thrive, adult • Fluid balance, readiness for enhanced • Fluid volume, deficient • Fluid volume, deficient risk for • Fluid volume excess • Fluid volume, imbalanced, risk for • Infant feeding pattern, ineffective

• Nutrition: imbalanced, less than body requirements

• Nutrition: imbalanced, more than body requirements

• Nutrition: imbalanced, risk for more than body requirements

• Nutrition, readiness for enhanced • Oral mucous membrane, impaired • Swallowing, impaired Gastro • *Jaundice, neonatal • Liver function, impaired, risk for • Nausea Growth and development • Dentition, impaired • Development delayed, risk for • Growth, disproportionate, risk for • Growth and development, delayed Health promotion/Education • Health maintenance, ineffective • Health management, self, ineffective • Health-seeking behaviors (specify) • Immunization status, readiness for

enhanced • Knowledge deficient (specify) • Knowledge (specify), readiness for

enhanced • Therapeutic regime management:

family ineffective • Hygiene- ability to perform activities of daily living • *Neglect, self • Self care, readiness for enhanced • Self-care deficit, feeding • Self-care deficit, bathing • Self-care deficit, dressing • Self-care deficit, toileting Life Principles • *Activity planning, ineffective • Decisional conflict • Decision making, readiness for

enhanced • Moral distress • Noncompliance (specify) • Hope, readiness for enhanced • Hopelessness • Religiosity, impaired • Religiosity, readiness for enhanced • Religiosity, risk for impaired • Spiritual distress • Spiritual distress, risk of • Spiritual well being, readiness for

enhanced

Neurosensory- ability to perceive, integrate and respond to internal and external cues • Autonomic dysreflexia • Autonomic dysreflexia, risk for • Communication, impaired verbal • Communication, readiness for

enhanced • Confusion, acute • Confusion, acute, risk for • Confusion, chronic • Environmental interpretation

syndrome, impaired • Infant behavior, disorganized • Infant behavior, disorganized, risk for • Infant behavior, organized, readiness

for enhanced • Intracranial adaptive capacity,

decreased • Memory, impaired • Neurovascular dysfunction, peripheral

risk for • Sensory perception disturbed

(specify):visual, auditory, kinesthetic, gustatory, tactile, olfactory

• Unilateral neglect Pain/discomfort- ability to control internal/external environment to maintain comfort • *Comfort, impaired • Comfort, readiness for enhanced • Pain, acute • Pain, chronic Respiration- ability to provide and use oxygen to meet physiological needs • Airway clearance, ineffective • Aspiration, risk for • Breathing pattern, ineffective • Gas exchange, impaired • Spontaneous ventilation, impaired • Ventilatory weaning response,

dysfunctional (DVWR) Safety- ability to provide safe, growth-promoting environment • Body temperature, imbalanced, risk for • Contamination • Contamination, risk for • Falls, risk for • Home maintenance, ineffective • Hyperthermia • Hypothermia • Infection, risk for • Injury, risk for • *Maternal/fetal dyad, risk disturbed • Latex allergy response • Latex allergy response, risk for

• Perioperative positioning injury, risk for

• Poisoning, risk for • Protection, ineffective • Self mutilation • Self mutilation, risk for • Skin integrity, impaired • Skin integrity, impaired, risk for • Sudden infant death syndrome, risk for • Suffocation, risk for • Suicide, risk for • Surgical recovery, delayed • Thermoregulation, ineffective • Tissue integrity, impaired • Trauma, risk for • *Trauma, risk for vascular • Violence, self-directed risk for • Violence, other-directed, risk for • Wandering Sexuality (component of ego integrity and Social interaction)- Ability to meet requirements/characteristics of male/female role • *Childbearing process, readiness for

enhanced • Sexual dysfunction • Sexuality patterns, ineffective Social Interaction- ability to establish and maintain relationships • Attachment, parent/infant/child, risk

for impaired • Care giver role strain • Care giver role strain, risk for • Family processes, dysfunctional • Family processes, interrupted • Family processes, readiness for

enhanced • Loneliness, risk for • Parenting, impaired • Parenting, readiness for enhanced • Patenting, risk for impaired • *Relationships, readiness for enhanced • Role conflict, parental • Role performance, ineffective • Social interaction, impaired • Social isolation

Activity/Rest Activity intolerance: insufficient physiological or psychological energy to endure or complete required or desired daily activities Activity intolerance, risk for: at risk for experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities

Disuse syndrome, risk for: at risk for deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity Diversional activity, deficient: decreased stimulation from or interest or engagement in recreational or leisure activities Fatigue: an overwhelming, sustained sense of exhaustion and decreased capacity for physical mental work at usual level Insomnia: a disruption in amount and quality of sleep that impairs function Mobility: bed, impaired: limitation of independent movement from one bed position to another Mobility: physical, impaired: limitation in independent, purposeful physical movement for the body or of one or more extremities Mobility: wheelchair, impaired: limitation of independent operation of wheelchair within the environment Sedentary lifestyle: reports a habit of life that is characterized by a low physical activity level Sleep deprivation: prolonged periods without sleep (sustained natural, periodic suspension of relative unconscious) *Sleep pattern disturbed: time-limited interruptions of sleep amount and quality due to external factors Sleep, readiness for enhanced: a pattern of natural, periodic suspension of consciousness that provides adequate rest, sustains a desired lifestyle, and can be strengthened Transfer ability, impaired: limitation of independence movement between two nearby surfaces

Walking, impaired: limitation of independent movement within the environment on foot (or artificial limb) Circulation *Bleeding, risk for: at risk for a decrease in blood volume that may compromise health Cardiac output, decreased: inadequate blood pumped by the heart to meet metabolic demands of the body *Tissue perfusion, decreased cardiac tissue, risk for: risk for a decrease in cardiac (coronary) circulation *Tissue perfusion, ineffective, cerebral, risk for: risk for decrease cerebral tissue circulation *Tissue perfusion, ineffective, renal, risk for: at risk for a decrease in blood circulation to the kidney that may compromise health *Tissue perfusion, ineffective, gastrointestinal, risk for: at risk for decrease I gastrointestinal circulation Tissue perfusion, ineffective, peripheral: decrease in blood circulation to the peripheries that may compromise health *Shock, risk for: at risk fro an inadequate blood flow to the body’s tissues which may lead to life-threatening cellular dysfunction Ego Integrity Anxiety: vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, with the source often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat. Anxiety, death: vague uneasy feeling of discomfort or dread generated by perceptions of a real or imagined threat to one’s existence Body image, disturbed: confusion in mental picture of one’s physical self Coping, community, ineffective: pattern of community activities (for adaptation and problem solving) that is unsatisfactory for meeting the demands or needs of the community

Coping, community, readiness for enhanced: pattern of community activities for adaptation and problem solving that is unsatisfactory for meeting the demands or needs of the community but that can also be improved for management or current and future problems/stressors Coping, defensive: repeated projection of falsely positive self-evaluations based on self-protective pattern that defends against perceived threats to positive self regard Coping, family, compromised: usually supportive primary person (family member or close friend) provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that may be needed to manage or master adaptive tasks related to heath challenge Coping, family, disabled: behavior of significant person (family member or other primary person) that disables his or her capacity to effectively address tasks essential to either person’s adaptation to health challenges Coping, family, readiness for enhanced: effective management of adaptive tasks by family member involved with client’s health challenge, who now exhibits desire and readiness for enhanced health and growth with regard to self in relation to client Coping, (individual), readiness for enhanced: pattern of cognitive and behavioral efforts to manage demands that is sufficient for wellbeing and can be strengthened Coping, ineffective: inability to form a valid appraisal of internal or external stressors, inadequate choices of practical responses, and/or to access or use available resources Denial, ineffective: conscious or unconscious attempt to disavow anxiety the knowledge or meaning of an event, to reduce anxiety/fear, but leading to the detriment of health Energy field disturbed: a disruption of the flow of energy surrounding a person’s being, which results in a disharmony of mind and spirit Fear: response to perceived threat that is consciously recognized as a danger

Grieving: a normal complex process that includes emotional, physical, spiritual, social and intellectual responses and behaviors by which individuals, families and communities incorporate an actual, anticipated or perceived loss into their daily lives Grieving, complicated: a disorder that occurs after the death of a significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifest in functional impairment Grieving, risk for complicated: a t risk for a disorder that occurs after the death of a significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifest in functional impairment Health behavior, risk prone: impaired ability to modify lifestyle/behaviors in a manner consistent with a change in health status Human dignity, risk for compromised: at risk for perceived loss of respect and honor Personal identity, disturbed: inability to maintain an integrated and complete perception of self Post trauma syndrome: sustained maladaptive response to a traumatic, overwhelming event Post trauma syndrome, risk for: at risk for sustained maladaptive response to a traumatic, overwhelming event Power, readiness for enhanced: a pattern of participating knowingly in change that is sufficient for well-being and can be strengthened Powerlessness: perception that one’s own actions will not significantly affect an outcome, perceived lack of control over current situation or immediate happening Powerlessness, risk for: at risk for perceived lack of control over a situation and/or one’s ability to significantly affect an outcome Rape-trauma syndrome: sustained maladaptive response to forced, violent sexual act (penetration may not actually occur) against victim’s will and consent

Relocation stress syndrome: physiological and/or psychological disturbances that result from transfer from one environment to another Relocation stress syndrome, risk for: at risk for physiological and/or psychological disturbances that result from transfer from one environment to another *Resilience, impaired individual: decreased ability to sustain a pattern of positive responses to an adverse situation or crisis *Resilience, readiness for enhanced: a pattern of positive responses to an adverse situation or crisis that can be strengthened to optimize human potential *Resilience, risk for compromised: at risk for decreased ability to sustain a pattern of positive responses to an adverse situation or crisis Self-concept readiness for enhanced: a pattern of perceptions or ideas about the self that is sufficient for well-being and can be strengthened Self-esteem, chronic low: long-standing negative self-evaluations/feelings about self or self-capabilities Self-esteem, situational low: development of a negative perception of self-worth in response to a current situation Self-esteem, risk for situational low: at risk for developing negative perception of self-worth in response to a current situation Sorrow, chronic: cyclical, recurring and potentially progressive pattern of pervasive sadness that is experienced (by parent, or caregiver, or individual with chronic illness or disability) in response to continual loss throughout the trajectory of an illness or disability Stress, overload: excessive amounts and types of demands that require action Endo Blood glucose, risk for unstable: risk for variation of blood glucose/sugar levels from the normal range

Elimination Bowel incontinence: change in normal bowel elimination habits characterized by involuntary passage of stool Constipation: decrease in normal frequency of defecation, accomplished by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool Constipation, risk for: at risk for decrease normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool Constipation, perceived: self-diagnosis of constipation and abuse of laxatives, enemas, and/or suppositories to ensure a daily bowel movement Diarrhoea: passage of loose, unformed stools *Motility, dysfunctional gastrointestinal: increased, decreased, ineffective or lack of peristaltic activity within the gastrointestinal system *Motility, risk for dysfunctional gastrointestinal: risk for increased, decreased, ineffective or lack of peristaltic activity within the gastrointestinal system Urinary elimination, readiness for enhanced: a pattern of urinary functions that is sufficient for meeting eliminatory needs and can be strengthened Urinary elimination, impaired: disturbance in urine elimination Urinary incontinence, functional: inability of usually continent person to reach toilet in time to avoid unintentional loss of urine Urinary incontinence, overflow: involuntary loss of urine associated with over distention of the bladder Urinary incontinence, reflex: involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached Urinary incontinence, stress: sudden leakage of urine with activities that increase intra-abdominal pressure

Urinary incontinence, urge: involuntary passage of urine occurring soon after strong sense of urgency to void Urinary incontinence, risk for urge: at risk for involuntary loss of urine associated with a sudden, strong sensation or urinary urgency Urinary retention: incomplete emptying of the bladder Food/fluid Breastfeeding, effective: mother-infant dyad/family exhibits adequate proficiency and satisfaction with the breastfeeding process Breastfeeding, ineffective: dissatisfaction or difficulty a mother, infant or child experiences with the breastfeeding process Breastfeeding, interrupted: break in the continuity of the breastfeeding process as a result of inability or inadvisability to put baby to breast for feeding Electrolyte imbalance, risk for: at risk for change in serum electrolyte levels that may compromise health Failure to thrive, adult: progressive functional deterioration of a physical and cognitive nature. The individuals ability to live with multisystem diseases, cope with ensuring problems and manage his/her care is remarkably diminished Fluid volume, readiness for enhanced: a pattern of equilibrium between fluid volume and chemical composition of body fluids that is sufficient for meeting physical needs and can be strengthened Fluid volume, deficient: decreased intravascular, interstitial and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level) Fluid volume, deficient, risk for: at risk for experiencing vascular, cellular, or intracellular dehydration Fluid volume, excess: increased isotonic fluid retention Fluid volume, imbalanced, risk for: at risk for decrease, increase, or rapid shift form one to the other of intravascular, interstitial and/or intracellular fluid (refers to body fluid loss, gain or both)

Infant feeding pattern, ineffective: impaired ability to suck or coordinate the suck-swallow response resulting in inadequate oral nutrition for metabolic needs Nutrition: imbalanced, less than body requirements: intake of nutrients insufficient to meet metabolic needs Nutrition: imbalanced, more than body requirements: intake of nutrients that exceeds metabolic needs Nutrition: imbalanced, risk for more than body requirements: at risk for intake of nutrients that exceeds metabolic needs Nutrition, readiness for enhanced: a pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened Oral mucous membrane, impaired: disruptions of lips and soft tissues of the oral cavity Swallowing, impaired: abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal or oesophageal structure or function Gastro *Jaundice, neonatal: the yellow orange tint of the neonate’s skin and mucous membrane that occurs after 24hours of life as a result of unconjugated bilirubin in the circulation Liver function, impaired, risk for: at risk for a decrease in liver function that may compromise health Nausea: an subjective unpleasant, wave-like sensation in the back of the throat, epigastium or throughout the abdomen that may or may not lead to vomiting Growth and development Dentition, impaired: disruption in tooth development/eruption patterns or structural integrity of individual teeth Development delayed, risk for: at risk for delay of 25% or more in one or more of the areas of social or self regulatory behavior, or in cognitive, language, gross or fine motor skills Growth disproportionate, risk for: at risk for growth above the 97th percentile or below 3rd percentile for age, crossing two percentile channels

Growth and development, delayed: deviations from age-group norms Health and promotion/Education: Health maintenance, ineffective: inability to identify, manage, or seek out help to maintain health Health management, self, ineffective: pattern of regulating and integrating into daily living a therapeutic regime for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals Health-seeking behaviors (specify): active seeking (by individual in stable health) of ways to alter personal health habits and/or environment to move toward higher level of health Immunization status, readiness for enhanced: a pattern to conforming to local, national, and/or international standards of immunization to prevent infectious disease/s that is sufficient to protect a person, family or community and can be strengthened Knowledge deficient (specify): absence or deficiency of cognitive information related to a specific topic Knowledge (specify), readiness for enhanced: the presence or acquisition of cognitive information related to a specific topic is sufficient for meeting health-related goals and can be strengthened Therapeutic regime management: family ineffective: pattern of regulating and integrating into family processes a program for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals Hygiene *Neglect, self: a constellation of culturally framed behaviors involving one or more self-care activities in which there is a failure to maintain a socially acceptable standard of health and well-being Self care, readiness for enhanced: a pattern of performing activities for oneself that helps to meet health-related goals and can be strengthened Self-care deficit, feeding: impaired ability to perform or complete feeding activities

Self-care deficit, bathing: impaired to perform or complete bathing/hygiene activities for self Self-care deficit, dressing: impaired ability to perform or complete dressing and grooming activities for self Self-care deficit, toileting: inability to perform or complete toileting activities for self Life principles *Activity planning, ineffective: inability to prepare for a set of actions fixed in time and under certain conditions Decisional conflict: uncertainty about course of action to be taken when choice among competing actins involves risk, loss or challenge to values and beliefs Decision making, readiness for enhanced: a pattern choosing courses of action that is sufficient for meeting short and long-term health-related goals and can be strengthened Moral distress: response to the inability to carry out one’s chosen ethical/moral decision/action Noncompliance (specify): behavior of person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed on by the person (and/or family and/or community) and health care professional; in the presence of an agreed-on, health promoting, or therapeutic plan, person’s or caregiver’s behavior is fully or partially nonadherant and may lead to clinically ineffective or partially ineffective outcomes Hope, readiness for enhanced: a pattern of expectations and desires that is sufficient for mobilizing energy on one’s own behalf and can be strengthened Hopelessness: subjective state in which individual sees limited or unavailable alternatives or personal choices and is unable to mobilize energy for problem solving on his or her own behalf Religiosity, impaired: impaired ability to exercise reliance on beliefs and/or participate in rituals of a particular faith tradition

Religiosity, readiness for enhanced: ability to increase reliance on religious beliefs and/or participate in rituals of a particular faith tradition Religiosity, risk for impaired: at risk for an impaired ability to exercise reliance on beliefs and/or participate in rituals of a particular faith tradition Spiritual distress: impaired ability to experience and integrate meaning and purpose in life through the individual’s connectedness with self, others, art, music, literature, nature or a power greater than oneself Spiritual distress, risk of: at risk for an impaired ability to experience and integrate meaning and purpose in life through the individual’s connectedness with self, others, art, music, literature, nature or a power greater than oneself Spiritual well being, readiness for enhanced: ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than oneself that can be strengthened Neuro Autonomic dysrelexia: life threatening, uninhibited sympathetic response of the nervous system to a noxious stimulus after spinal cord injury at T7 or above Autonomic dysreflexia, risk for: at risk for life threatening, uninhibited response of the sympathetic nervous system; post-spinal shock; in an individual with spinal cord injury or lesion at T6 or above (has been demonstrated in clients with injuries at T7 or T8) Communication, impaired verbal: decreased, delayed or absent ability to receive, process, transmit, and use a system of symbols Communication, readiness for enhanced: pattern of exchanging information and ideas with others that is sufficient for meeting one’s needs and life’s goals and can be strengthened Confusion, acute: abrupt onset of reversible disturbances of consciousness, attention, cognition and perception that develop over a short period of time

Confusion, acute, risk for: at risk for reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time Confusion, chronic: irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by deceased ability to interpret environmental stimuli and decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation, and behavior Environmental interpretation syndrome, impaired: consistent lack of orientation to time/place/person/circumstances over more than 3-6 months necessitating a protective environment Infant behavior, disorganized: disintegrated physiological and neurobehavioral responses to the environment Infant behavior, disorganized, risk for: risk for alteration in integrating and modulation of the physiological and neurobehavioral systems of functioning (i.e. autonomic, motor, state, organization, self-regulatory, and attentional-interactional systems) Infant behavior, organized, readiness for enhanced: a pattern of modulation of the physiological and behavioral systems of functioning (i.e. autonomic, motor, state, organization, self-regulatory, and attentional-interactional systems) in an infant that is satisfactory but that can be improved Intracranial adaptive capacity, decreased: intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes are compromised, resulting in repeated disproportionate increases in intracranial pressure (ICP) in response to a variety of noxious and non-noxious stimuli Memory, impaired: inability to remember or recall bits of information or behavioral skills Neurovascular dysfunction, peripheral risk for: at risk of disruption in circulation, sensation or motion of an extremity

Sensory perception, disturbed (auditory, gustatory, kinesthetic, olfactory, tactile, visual): change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli (auditory- hearing) (gustatory- taste) (kinesthetic-muscle sense) (olfactory- smell) (tactile- touch) (visual- see) Unilateral neglect: impaired sensory and motor response, mental representation and spatial attention of the body, and the corresponding environment characterized by inattention to one side and over attention to the opposite side. Left side neglect is more severe than persistent right side neglect Pain/discomfort *Comfort, impaired: perceived lack of ease, relief and transcendence in physical, psychospiritual, environmental and social dimensions Comfort, readiness for enhanced: a pattern of ease, relief and transcendence in physical, psychospiritual environmental and/or social dimensions that can be strengthened Pain, acute: unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of less than 6 months Pain, chronic: unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a duration of more than 6 months Respiration Airway clearance, ineffective: inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway Aspiration, risk for: at risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids or fluids into the tracheobronchial passages Breathing pattern, ineffective: inspiration and/or expiration that does not provide adequate ventilation

Gas exchange, impaired: excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane Spontaneous ventilation, impaired: decreased energy reserve result in an individual’s ability to maintain breathing adequate to support life Ventilatory weaning response, dysfunctional (DVWR): inability to adjust to lowered levels of mechanical ventilator support that interrupts and prolongs the weaning process Safety Body temperature, imbalanced, risk for: at risk for failure to maintain body temperature within normal range Contamination: exposure to environmental contaminates in doses sufficient to cause adverse health effects Contamination, risk for: accentuated risk of exposure to environmental contaminants in doses sufficient to cause adverse health effects Falls, risk for: increased susceptibility to falling that may cause physical harm Home maintenance ineffective: inability to independently maintain a safe and growth-promoting immediate environment Hyperthermia: body temperature elevated above normal range Hypothermia: body temperate below normal range Infection, risk for: at increased risk for being invaded by pathogenic organisms Injury, risk for: at risk of injury as a result of the interaction of environmental conditions interacting with the individual’s adaptive and defensive resources *Maternal/fetal dyad, risk disturbed: at risk for disruption of symbiotic maternal/fetal dyad as a result of comorbid or pregnancy related complications Latex allergy response: a hypersensitive reaction to natural latex rubber products

Latex allergy response, risk for: risk of hypersensitive reaction to natural latex rubber products Perioperative positioning injury, risk for: at risk for inadvertent anatomical and physical changes as a result of posture or equipment used during an invasive/surgical procedure Poisoning, risk for: accentuated risk for accidental exposure to, or ingestion of, drugs or dangerous products in doses sufficient to cause poisoning Protection, ineffective: deceased in the ability to guard self from internal or external threats such as illness or injury Self mutilation: deliberate self-injurious behavior causing damage with the intent of causing on-fatal injury to attain relief of tension Self mutilation, risk for: at risk of deliberate self-injurious behavior causing damage with the intent of causing on-fatal injury to attain relief of tension Skin integrity, impaired: altered epidermis and/or dermis Skin integrity, impaired, risk for: at risk for skin being adversely altered Sudden infant death syndrome, risk for: presence of risk factors for sudden death of an infant under 1 year of age Suffocation, risk for: accentuated risk of accidental suffocation (inadequate air available for inhalation) Suicide, risk for: at risk for self-inflicted, life-threatening injury Surgical recovery, delayed: extension of number of postoperative days required to initiate and perform activities that maintain life, health, and well-being Thermoregulation, ineffective: temperature fluctuation between hypothermia and hyperthermia Tissue integrity, impaired: damage to mucous membrane, corneal, integumentary or subcutaneous tissue

Trauma, risk for: accentuated risk of accidental tissue injury (eg: wound, burn, fracture) *Trauma, risk for vascular: at risk for damage to a vein and its surrounding tissues related to the presence of a catheter and/or infused solutions Violence, self-directed risk for: at risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to self Violence, other-directed, risk for: at risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to others Wandering: meandering, aimless or repetitive locomotion that exposes the individual to harm; frequency incongruent with boundaries, limits or obstacles Sexuality (component of ego integrity and Social interaction) *Childbearing process, readiness for enhanced: a pattern of preparing for, maintaining and strengthening a healthy pregnancy an childbirth process and care of newborn Sexual dysfunction: the state in which an individual experiences a change in sexual function during sexual response phases of desire, excitation, and/or orgasm, which is viewed as unsatisfying, unrewarding, inadequate Sexuality patterns, ineffective: expressions of concern regarding own sexuality Social Interaction Attachment, parent/infant/child, risk for impaired: disruption of the interactive process between parent/significant other and infant/child that fosters the development of a protective and nurturing reciprocal relationship Care giver role strain: difficulty in performing family caregiver role Care giver role strain, risk for: caregiver is vulnerable for felt difficulty in performing family caregiver role

Family processes, dysfunctional: psychosocial, spiritual and physiological functions of the family unit are chronically disorganized, which leads to conflict, denial of problems, resistance to change, ineffective problem solving and a series of self-perpetuating crises Family processes, interrupted: change in family relationships and/or functioning Family processes, readiness for enhanced: a pattern of family functioning that is sufficient to support the well-being of family members and can be strengthened Loneliness, risk for: at risk of experiencing discomfort associated with a desire or need for more contact with others Parenting, impaired: inability of primary caretaker to create, maintain or regain an environment that promotes optimum growth and development of the child Parenting, readiness for enhanced: pattern of providing environment for children or other dependent person/s that is sufficient to nurture growth and development and can be strengthened Parenting, risk for impaired: risk for inability of primary caretaker to create, maintain, or regain an environment that promotes optimum growth and development of the child *Relationships, readiness for enhanced: a pattern of mutual partnership that is sufficient to provide each other’s needs and can be strengthened Role conflict, parental: parent experience of role confusion and role in response to crisis Role performance, ineffective: patterns of behavior and self-expression that do not match the environmental context, norms and expectations Social interaction, impaired: insufficient or excessive quantity or ineffective quality of social exchange Social isolation: aloneness experienced by the individual and perceived as imposed by others and as a negative or threatened state Readiness to enhance = willingness to strengthen or improve

LOSANGELESHARBORCOLLEGEWEEKLYCLINICALEVALUATIONforNURSING345

[R.8.28.17] 1

Student: ClinicalInstructor:

Agency:

Semester:

EvaluationCriteria• Satisfactory:Clinicalperformancedemonstratescontinued

growthtowardscoursecompetencies.Behaviorsareconsistent,safe,andperformedatexpectedlearnerleveldescribedinthestudentcompetencybehaviordescriptorsforsatisfactoryperformance.

• Unsatisfactory:Behaviorsperformedareunsafe.Omitsstudentbehaviorsrequiredtoachievecoursecompetencies.Studentbehaviorslackknowledgebaseandskillcompetenciesexpected.

(*)-RepresentsCriticalCompetencyBehaviors:CompetencyBehaviorsmustbemetinordertopasstheclinicalcomponentofthiscourse.“Unsatisfactory”dailyratingswillbegivenforthefollowingbehaviors:• An“Unsatisfactory”ratinginanycriticalbehavior(delineatedbyan“*”).• Threeormore“NeedsImprovement”ratingsinanyareaononedayof

clinicor1“Unsatisfactory”ratinginanon-criticalbehaviorand1“NeedsImprovement”in1clinicday

TheStudentmustdemonstratea“Satisfactory”levelofperformancefor75%oftheclinicalrotationinordertopassthecourse.Two“Unsatisfactory”clinicalweekswillresultinaclinicfailure.

COMPETENCIES/PERFORMANCECRITERIAI.INCORPORATETHENURSINGPROCESSUSINGTHEROYADAPTAONMODELINCARINGFORINDIVIDUALSANDGROUPSACROSSTHELIFESPANANDDEVELOPMENTALSTAGES.1. Collectscomprehensiveassessmentdatathatincludesthepatient’svalues,preferences,expressedneeds,anddevelopmental,

emotional,cultural,religious,andspiritualinfluences.2. Createsanursinghistoryandassessmentonacardiac/pulmonary/criticalcarepatientthatcategorizeineffectivebehaviorsthat

affectadaptationinthefourmodes:Physiological,self-concept,rolefunction,andinterdependence.*3. Analyzeassessmentdatatodetermineactualandpotentialnursingdiagnosesandformulate/proposeexpectedoutcomes.4. Proposesactualandpotentialnursingdiagnosesandformulatesexpectedoutcomesbasedonthepatientvalues,preferences,and

expressedneeds.*5. Coordinatewiththepatientandinter-professionalteamtodevelopaplanthatprescribesstrategiesandalternativestoachieve

expectedoutcomes.6. Implementidentifiedplan.7. Evaluateprogresstowardattainmentofoutcomesandmodifyplanofcareasneeded.*

WEEK/DATE 1 2 3 4 5 6

Evaluator Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst.

SAT.

ORIENT

N.I.

UNSAT.

N/A

II.INTEGRATEPROFESSIONALBEHAVIORFORNURSINGPRACTICE.1. Internalizesone’sroleasanurseinwaysthatreflectintegrity,responsibility,ethicalpractices,andanevolvingidentityasanurse

committedtoevidencebasedpractice,caring,advocacy,andsafe,qualitycarefordiversepatientswithinafamilyandcommunitycontext.

2. IntegratestheCodeofEthics,StandardsofPractice,andpoliciesandproceduresofLosAngelesHarborCollege,nursingprogram,andclinicalagenciesintopractice.

3. Codifiesappropriatebehaviors,e.g.promptandtimelyarrivaltoclassandclinic;adherencetouniformstandards;attendance,honesty;andattitude.*

4. Acceptsaccountabilityandresponsibilityforownactions.5. Advocatesforpatientsandfamiliesinwaysthatpromotetheirself-determination,integrity,andongoinggrowthashumanbeings.6. Evaluatesownperformancecorrectlyandthoughtfully.*

WEEK/DATE 1 2 3 4 5 6Evaluator Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst.SAT.

ORIENT

N.I.

UNSAT.

N/A


[R.8.28.17] 2

III.DEMONSTRATECLINICALDECISIONMAKINGTHATISACCURATEANDSAFE.1. Formulatesanddevelopscriticalthinkinginmakingclinicaldecisions(e.g.nursingassessment,informationregardingmedicalhistory,

assessment,diagnostictests,laboratoryvalues,andmedications)todevelopanindividualizedplanofcareforthepatient.*2. Integratesandvalidatesstimuliofeffectiveandineffectivebehaviors.3. Organizesanddocumentsallrelevantinformationanduseappropriateresourcesandreasoningforclinicaldecision-making.


ORIENT

N.I.

UNSAT.

N/A

IV.PROVIDESAFE,PATIENT-CENTEREDCARE.1. Relatesknowledgeofpathophysiologyandpharmacotherapyforpatients.*2. Assesseslearningneeds,developteachingplans,implementteachingandevaluateeffectiveness.3. Respectsandencouragesindividualexpressionofpatientvalues,preferences,andexpressedneeds.4. Providesandintegratespatient-centeredcarewithsensitivityandrespectfordevelopmentalstage,values,customs,religion,ethnicity,and

culture.5. Assessesandtreatspainandsufferinginlightofpatientvalues,preferences,andexpressedneeds.6. Performsnursingskillscompetentlyandsafelyaccordingtocollegeoragencypolicyandprocedureguidelines.e.g.follow8rightsof

medicationadministration.*7. AdherestocurrentBehavioralHealthNationalPatientSafetyGoals.8. Implementsstrategiestopreventandreduceharm.*WEEK/DATE 1 2 3 4 5 6Evaluator Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst.SAT.

ORIENT

N.I.

UNSAT.

N/A

V.FUNCTIONEFFECTIVELYWITHINNURSINGANDINTERPROFESSIONALTEAMSUTILIZINGEFFECTIVE

COMMUNICAITONSTRATEGIES.1. Functionscompetentlywithinscopeofpracticeasamemberofthehealthcareteamanddescribethescopesofpracticeandrolesof

healthcareteammembers(e.g.physician,nursemanager,clinicalsocialworker,spiritualpractitioner,unitsecretary,andsoforth).2. Consistentlydevelopstherapeuticcommunicationtechniqueswithinterdisciplinaryteammemberstoassistthepatient,family,and

significantotherstocopeandresolveproblems3. Interactseffectivelywithpatient,family,staff,andinstructorandactivelyparticipatesinpre-andpostconferences.*4. Formulatescommunicationpracticesthatminimizerisksassociatedwithhandoffsamongprovidersacrosstransitionsofcare(SBAR).*5. Reportsineffectivebehaviors,accurate,pertinentinformation,andpatientconcernsinatimelymannertostaffand/orinstructor.*WEEK/DATE 1 2 3 4 5 6Evaluator Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst.SAT.

ORIENT

N.I.

UNSAT.


[R.8.28.17] 3

VI.INCORPORATEEVIDENCE-BASEDPRACTICESTHATSUPPORTCLINICALREASONING.1. Formulateevidence-basedpracticetoincludethecomponentsofresearchevidence(etiology,pathophysiology,medicationmanagement,stress

managementtechniques),clinicalexpertise,andpatient/familyvalues.*2. Critiquesefficientandeffectivesearchstrategiestolocatereliablesourcesofevidencethatwillprovidetheabilitytomakejudgmentsin

practice,substantiatedwithevidence,thatintegratenursingscienceintheprovisionofsafe,qualitycareandpromotehealthofpatientswithinafamilyandcommunitycontext.

3. Verifytheevidencethatunderliesclinicalnursingpracticetochallengethestatusquo,questionunderlyingassumptions,andothernewinsightstoimprovethequalityofcareforpatients,families,andcommunities.


ORIENT

N.I.

UNSAT.

N/A

VII.IDENTIFYAREASFORIMPROVEMENTINQUALITYANDSAFETYOFHEALTHCARESYSTEMS.1. Examineavarietyofsourcesofinformationtoreviewoutcomesofcareandidentifypotentialareasforimprovement.(e.g.decreasedhospital

acquireinfection,skinulcers,restraintrates,andfallrates).*2. Identify1qualitymeasurefortheclinicalunit3. Compareandcontrastnursingandotherhealthprofessionsaspartsofsystemsofcarethataffectoutcomesforpatients,families,and

communities.4. Completescaresafely,costeffectively,organizedandtimelytoimprovethequalityofcare.5. Verifymeasurableoutcomesoncareplanstoevaluatecare.6. Utilizesqualityandsafetymeasuresinplaceattheclinicalagency(MorseFallScale,RapidResponse,Bradenscale,etc.).*7. Relatesclinicalsafetyconcernsforgroupdiscussionandresolutioninclinicalconference.WEEK/DATE 1 2 3 4 5 6Evaluator Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst.SAT.

ORIENT

N.I.

UNSAT.

N/A

VIII.UTILIZETECHNOLOGYTORESEARCHPATIENTINFORMATIONANDCOMMUNICATEWITHINTERPROFESSIONALTEAMS,MANAGEKNOWLEDGE,MITIGATEERROR,ANDSUPPORTDECISIONMAKING.

1. Demonstratesuccessfulnavigationanddocumentationwithintheelectronichealthrecordintheclinicalsetting.2. Examineappropriateresources,collectedelectronicallyorothermeanstocommunicatewiththeinterprofessionalteamsandsolvepatient

problems.3. Maintainspatientconfidentialityandsecurityofallhealthrecords.*4. Researchesandprovidesappropriatecommunity–basedsupportresources,computer-basedsupport,orappsthatcanenhancepatientwell-

being.WEEK/DATE 1 2 3 4 5 6Evaluator Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst. Stud. Inst.SAT.

ORIENT

N.I.

UNSAT.

N/A


[R.8.28.17] 4

STUDENTREFLECTIONS:IDENTIFYONE(1)DIFFERENTAREAOFQSENEACHWEEKTHATYOUAREGOINGTOREFLECTUPONFROMTHEPREVIOUSPAGES/TABLES.Writeaboutfeelings,opinionsandconcernsregardingpatientcareactivitiesthatwentwellandnotsowell,transferoftheoreticalknowledgeandnursinginterventionsthatpromotedeffectiveadaptationofyour

Reflection Comments: USE BACK OF SHEET AS NEEDED List Week’s Nursing Diagnoses

Circle/List Procedures Performed

Week1 -Safety and Patient-Centered Care

Meds: NG/GT/PO/IM/SQ/IVPB IVP (SL/Central) /FSBS/Insulin Suction/in-line/trach/oral Foley Insert/DC Vent/arterial line/ABG sampling Central Line dressing/Care Other:

Week 2- Teamwork and Collaboration


Week 3- Evidence Based Practice


Week 4- Informatics


Week 5- Quality Improvement


Week 6



[R.8.28.17] 5

client.Writecommentsrelatedtoresolutionofperformance,lessonslearned,proceduresperformed.

Instructor’WeeklyFeedbackregardingstudentclinicalperformance:Statepositiveperformanceandsuggestionsforimprovement.Circleweeklyperformancelevelrating.

StudentInitial

Week1OrientationDay____punctual____dressedappropriately____worenametag____broughtallmaterials_____completedHospitalorientationrequirement______completedunitorientationPatientcare:

WeeklyRating:Sat.NIUnsat

Week2


Week3


Week4


Week5


Week6(Summary)


TotalPoints_________/ClinicalPracticum_________TheoryGrade__________ClinicGrade____________TotalSkills:IVPB__________IVP________CentralLineCare(CVADS)_________Insulin____________Suctioning:In-line_________/trach___________/oral___________CentrallineDressingchange__________StudentSignatureClinicInstructorSignature______________________Date:_____________


[R.8.28.17] 6

Instructor’s Additional Comments:


[R.8.28.17] 7

Competency

Satisfactory(Movingtowardindependentlevel.PerformingasExpectedforthislevel)

Unsatisfactory(Dependentlevel,significantconcernsforsafety)

I.APPLYTHENURSINGPROCESSUSINGTHEROYADAPTATIONMODELINCARINGFORINDIVIDUALSANDGROUPSACROSSTHELIFESPANANDDEVELOPMENTALSTAGES.

Utilizingappropriateguidelines,resources,&assessmenttechniques,demonstratesstepsofthenursingprocess.Identifiesadaptive&ineffectivebehaviorsinallfourmodes.Includessubjective&objectivedata.Identifiesstimuliforineffectivebehaviors,includespatientvalues,preferences,expressed-needs,growth&developmentalstage,culture,spiritual,adaptionlevels,&economicfactors,astheyrelatetothepatient.H&Aformscontain95%ofpertinentdata(e.g.lab,diagnostictests,modeassessmentdata,BMI,generalassessment-<2areasneedingminorcorrectionsoradditions).Identifies>3primeNursingdiagnoses(ND).Identifies>3pertinentmanipulatablestimuliforeachND.Maincareplansreflectprioritynursingdiagnosis.Goalstatedareappropriateforpatient.Has>3outcomesmeasurable&withrealisticcriticaltimes.Identifies95%oftherapeuticnursinginterventions(NI)relatedtostatedoutcomes.GivesrationaleforeachNI.Evaluatesprogresstowardsoutcomes&revisesNIPRN.Receives>75%(75points)or11.5/15awardedoneachCP.

Doesnotutilizeappropriateguidelinesorresources.Submitsworklate.Doesnotutilizeappropriateassessmenttechniques.HistoryandAssessmentcontainslessthan75%ofpertinentdata.Doesnotrelatepatientvalues,preferences,expressed-needs,growth&developmentalstage,culture,spiritual,adaptionlevels,&economicfactorswhenindicated.Inaccuratedataobtained.Failuretoidentifyallsignificantrelatedsubjectiveandobjectivedataforselectednursingdiagnosis.Failstodemonstrateunderstandingofthelinkbetweenstimuliandsupportingbehaviors.Cannotverbalizestimuliforpatientbehaviorswithmajorcues.Careplannotindividualized.Failstodemonstratetheabilitytoprioritizenursingdiagnoses.Outcomesarenotmeasurableorlackofrealisticcriticaltimefor3ormoreoutcomes.Nursinginterventionsdonothaverelatedrationales.Missing3ormorekeyinterventionsonplanofcare.Doesnotevaluateoutcomesorrevisenursinginterventionsasindicated.Score<75%oncareplanor<11.5/15ineachCP.

II.DISPLAYPROFESSIONALBEHAVIORFORNURSINGPRACTICE.

Presentstotheclinicalsettinginapunctualmanner,dressedappropriately,withnamebadge(andhospitalrequiredIDifindicated),andallprep/paperworkcompleted.Participatesinpreandpostclinicalconference.Researchesandadherestoagencyguidelinesandschoolpolicies.Conductsselfinanhonestandethicalmannerwithinthelegallimitsandscopeofpracticeofastudentnurse.Treatsstaff,patients,instructors,andpeersrespectfullyandwithdignity.

Anytardinessorabsencewithoutnotificationofinstructororunit.Arrivinglatetogroupsorwhenleadingagroup.Doesnotcomplywithinstructor’srequest/instructions.Doesnotcorrectbehaviorsafterbeingdiscussedbyinstructor.Isdishonest,disrespectfulorargumentativewithpatient,staff,orinstructor.Leavesunitwithoutreportingtoprimarynurseorinstructor.Assignmentssubmitted>1daylate,or<2weeklyassignmentssubmittedlate.Consistentuseofunapprovedabbreviations.Leavescomputerscreenopen,>2times.Non-compliancewiththecollegedresscode.Doesnotcorrectlyevaluateselfforsecondweekduringtherotation.Doesnotreflectonhowtocorrectorimproveuponmajorweakness.

III.DEMONSTRATECLINICALDECISIONMAKINGTHATISACCURATEANDSAFE.

Clinicalprepandcareplanssupportedbyevidencebasenursingtheory.Utilizesagencycareplans,coremeasuresandcarebundlesasguidesforpatientcare.CompletesH&Awithlessthan3itemsneedingcorrection.Recognizesineffectivephysiologicalresponses,diagnostictestandlabvalues.Recordspertinentclinical/laboratoryvaluesonmedicationadministrationrecordsheet.Prioritizenursinginterventiontopromotepositiveoutcome.Articulatesetiologyforpatient’sbehaviorandtherapeuticnursinginterventions.

ConsistentmissingorinaccurateassessmentdataontheH&A,multipleblanks.Doesnotrecognizeorreportadversemedicationsideeffectsorlabvalues.Majoromissioninplanofcare.Doesnotprioritizecare.Doesnotrecognized/reportsignificantchangeinpatientcondition.Unabletoverbalizestimuliwithmajorcuesfrominstructor.Pathoandprepnotcompletedpriortoclinicormissingcriticalclinicaldata.


[R.8.28.17] 8

Competency

Satisfactory(Movingtowardindependentlevel.PerformingasExpectedforthislevel)

Unsatisfactory(Dependentlevel,significantconcernsforsafety).

IV.PROVIDESSAFE,PATIENT-CENTEREDCARE.

IdentifiesandcomplieswithNationalBehavioralHealthPatientSafetyGuidelines.Immediatelyreportsandpatientbehaviorthatisunsafetothechargenurseorclinicalsupervisor.Seeksassistanceormentorshipwhenneeded.Abletorelateknowledgeofthemechanismofaction,indication,dosagerange,therapeuticeffect,laboratoryvalues,sideeffectsandnursingactionsrelatedtoallmedications.Followshospitalpolicyforunitcodes,fallprecautionsandrestraints).Developsaplanforpatient,familyandgroupteachingandevaluateswhetherlearninghasoccurred.Assessesdevelopmentalstage,values,customs,religion,ethnicityandcultureinallcaregiven.Administersmedsfollowingallrights.Recognizesandcorrectsbreakinsterility.Demonstratessafenursingpracticeandperformsnursingskills/practicumat>75%.

FailstoadheretoNationalBehavioralHealthPatientSafetyGuidelines.Cannotanswerinstructor'squestionsregardingsignificantpatientinformation,medicationandplanofcare.Needsmajorpromptorinstructorinterveningtosafelyperforminterventions.Doesnotaskquestionswhenunsureofpatientstatusorappropriateinterventions.Doesnotfollowstandardprecautionsorhospitalpoliciesconcerningpatientsafety(fallprecautions,restraints,unitcodes,Rapidresponse).Doesrecognizeneedtoknowresultsofdiagnosticreports/labvalues.Nouseofhandwashingoruniversalprecautionswhennecessary.Doesnotnotifyinstructoroferrors.Nouseofpatientidentifierwhenprovidingcare.Commitactionsthatcauseorhavethepotentialtocausesignificantharmtoapatient.eg.Doesnotcorrectbreakinsterility,orfollowmedrights.Performsnursingskillunsafelyorrequiremajor>50%coachingfrominstructor.Performsnursingskill/practicum<75%.

V.FUNCTIONEFFECTIVELYWITHINNURSINGANDINTERPROFESSIONALTEAMSUTILIZINGEFFECTIVECOMMUNICAITONSTRATEGIES.

Abletorelateknowledgeofthedifferentrolesofthemembersofthehealthcareteamandcommunicatewithappropriatemembertomeetpatientneeds.Consistentlyrecognizesblockingtechniquesandprovidestherapeuticalternateseachoccurrence.Demonstratesanon-judgmentalacceptanceofviewsdifferingfromown.Assessandreportsclinicalconditionorpainconsistentlythroughoutshift.AbletodemonstrateSBARcommunicationinassociationwithpatienthandoffsutilizinghandout/format.

Doesnotutilizecommunicationchannelswithmembersofthehealthcareteamasindicatedbypatientneeds.Displaysajudgmentalattitudetowardpatientsorothermembersofthehealthcareteam.Doesnotassessorreportdetrimentalchangeinconditionorpaintoinstructororassignednurse.UnabletorelatepertinentinformationinSBARhandout/format

VI.INCORPORATEEVIDENCE-BASEDPRACTICESTOSUPPORTCLINICALREASONING.

Demonstratesabilitytoresearchappropriateevidence-basepracticesthroughaccuratecompletionofprep/pathophysiologycaresheetassignmentswithomissionoflessthantwomainareasofimportance.Identifiesevidence-basedclinicalpractices(carebundles,coremeasures)Abletoverbalizeandincorporatereliableevidence-baseddatawhenplanningandprovidingpatientcare.

Cannotlocateresourcesforobtainingevidence-baseddatatoprovideforpatientcare.Missinggreaterthan3areasofevidence-baseddatathatdriveappropriateclinicalreasoningforcaregiventopatientsonthepathophysiologysheet.Cannotdescribeevidence-basedguidelinesanddoesnotfollowcarebundlesorcoremeasuresforcaregivenintheclinicalsetting.

VII.IDENTIFYAREASFORIMPROVEMENTINQUALITYANDSAFETYOFHEALTHCARESYSTEMS.

Abletoidentifyindividualmeasuresthatmovethesystemtoimprovedqualityandsafety.Addressespersonalbiasesandstereotypesinpre-andpostconference.Utilizesqualityandsafetymeasuresinplaceattheclinicalagency.

Unabletoverbalizeordemonstratesystembasedthinking.Cannotverbalizepotentialqualityorsafetyissuesintheclinicalsetting.Doesnotrecognizepersonalbiases.Doesnotfollowprotocolsofsafetyandqualityattheclinicalagency.

VIII.UTILIZETECHNOLOGYTORESEARCHPATIENTINFORMATIONANDCOMMUNICATEWITHINTERPROFESSIONALTEAMS,MANAGEKNOWLEDGE,MITIGATEERROR,ANDSUPPORTDECISIONMAKING.

Completesallhospital-requiredtrainingforaccesstoelectronicmedicalrecords(EMR).Maintainsintegrityofpersonalpasswords.DemonstratestheabilitytonavigateanddocumentintheEMRperagencyprotocol.AbletoutilizeEMRbasedresourcestopromotecommunication,manageknowledge,mitigateerrorandsupportdecision-making.Strictlymaintainspatientconfidentialityandreportsanybreachobserved.Researchesandanalyzescommunity-basedsupportresources,computer-basedsupportorevidence-basedappsthatenhancepatientwell-being.

UnabletonavigateordocumentwithintheEMRafterthesecondweekwithoutmajorpromptingfromclinicalinstructor.Sharespersonalpasswordstoelectronicmedicalrecordsystemwithothers.UnawareofmechanismswithintheEMRthatpromotecommunication,manageknowledge,mitigateerrorandsupportdecision-making.Breachofpatientconfidentialityinoral,writtenorsocialmediaform.Failstoresearchandanalyzescommunity-basedsupportresources,computer-basedsupportorevidence-basedappsthatenhancepatientwell-being.


[R.8.28.17] 9

Most communication breakdowns occur verbally between staff. Use the following format in shift to shift reports, Unit to Unit, Inter-facility reports during transfer. Name, Age, Room #

Reason for admission (CC) Diagnosis

Significant History

Procedures

Admitting MD

Allergies

Code Status

Vital Signs and any trends EKG Rhythm

Pain level/ Comfort function goal

O2, Artificial Airway, Ventilator settings, Vent weaning etc.

Mental status

Stat /One Time Medications & times /FSBS

Abnormal/pending lab tests

Abnormal/pending diagnostic tests

IV’s, Location, Type

Tubes, Drains

Skin Integrity

Fall Risk/ Restraints Diet/Swallowing Status

Isolation Status Other significant Info (ie. New orders, status changes, significant events, significant assessment findings, Plan of care


[R.8.28.17] 10

Los Angeles Harbor College

Associate Degree Nursing Program

Referral Form For Clinical Skills

Student Name _________________________ Clinical Instructor_____________________ Date ____________

Please practice and get checked off on the following procedure(s) within _________________. Review audio visual materials on designated procedure(s) below. Review Potter and Perry Clinical Skills book and Skills check off sheet, and practice clinical procedures in the Skills Lab. Ask the NLL assistant or student workers for supplies. When you are ready for check off, bring check off sheet to the NLL assistant. Return this signed form to your clinical instructor. √ off any procedure

needing refresher

PROCEDURE Semester MET PROFICIENCY

INSTRUCTOR COMMENTS

Vital Signs T, P, R, BP 1

Safety Check 1

Bed Making/bed bath 1

Oral-nasal pharyngeal suctioning 1

Application of Restraints 1

Staging pressure ulcers 1

Hanging IV bag 1

Preparing IV bag & tubing 1

Discontinuing IV or SL 1

Monitoring Blood Sugar 1

Environment Assessment 1

Insertion of NG tube 1

Administering NG feedings 1

Head to Toe Assessment 1

Administering Enema 1

Administering Harris Flush 1

Catheterization Female /Male 1

Sterile dressing Change 1

Clean and Dress a wound c an open drain 1

Wound irrigation 1

Obtaining wound culture 1

Isolation techniques, gloves, Cap, Mask, Gown 1

Hand washing 1

Oxygen Administration 1

PO, IM, SC ,rectal,(circle) med. admin. 1

IVPB administration 2

Changing Central Venous Dressing 2

Colostomy Care 2

Administering IVPB 2

Three way foley irrigation 2

Blood Transfusion 2

Lovenox or heparin admin. (circle one) 2

Postpartum Assessment 3

Newborn Assessment 3

Fetal Monitoring 3

Infant Gavage Feeding 3

Metriset administration of drugs 3

IV insertion 4

IV push meds 4

Tracheostomy Care 4

Nursing Instructor Signature _______________________________________ Date_______________________________

Documents

N345_ClinicSyllabus Revised 8.8.17