Course Syllabus Course Name: Course Numbernursing.ju.edu.jo/Lists/Courses/Attachments/26/Adult II...Brunner and Suddarth's textbook of medical surgical nursing (13th Ed.). Philadelphia,

01اإلصدار: الجامعة األردنية

01/04/2016التاريخ: QF-AQAC-03.02Aرقم النموذج:

1/12الصفحات: برنامج بكالوريوس التمري-اسم النموذج : مخطط المادة الدراسية

0 Approved by The School Board on September 28th, 2016

The University of Jordan

Accreditation & Quality Assurance Center

Course Syllabus

Course Name: Adult Health Nursing (2) (Clinical)

Adult Health Nursing Clinical (2)

Course Number: 0702309

The University of Jordan Course Syllabus Accreditation and Quality Assurance Center


SCHOOL OF NURSING

COURSE SYLLABUS

DEPARTMENT: CLINICAL NUIRSING DEPARTMENT

[SEMESTER ACADEMIC YEARI]

SECOND SEMESTER (2017/2018)

THE MISSION OF THE UNIVERSITY OF JORDAN

Providing students with fulfilling learning experiences, conducting knowledge-producing research,

and building firm societal ties, within an environment conducive to creativity, innovation, and

entrepreneurship; making efficient use of resources and forging fruitful partnerships.

THE VISION OF THE SCHOOL OF NURSING

To be a leading, global school in the areas of nursing education, research, and community service.

THE MISSION OF THE SCHOOL OF NURSING

The School of Nursing dedicates itself to improve health and wellbeing of society through preparing

professional nurses to provide quality nursing care, conduct research and provide community service.

The school provides a model learning environment that encourages life-long learning, innovation, and

professional and personal development.

SCHOOL OF NURSING’S CORE VALUES

Our values are derived from the Islamic Arabic heritage and the nursing profession which include:

integrity, equality, and justice; transparency and accountability; innovation and excellence;

leadership and teamwork; discipline; response; and most importantly caring.



1 Course title Adult Health Nursing Clinical (2)

2 Course number 0702309

3 Credit hours (theory, practical) Theory 3hours , practical 6 hours

Contact hours (theory, practical) Practical 12 hours /weekly

4. Class room: University of Jordan Hospital, Prince Hamzeh Hospital, and Al-Basheer Governmental Hospital, School of nursing labs

4 Prerequisites/co-requisites Prerequisite:(0702207)& Concurrent with (0702308)

5 Programtitle BS

6 Programcode 07

7 Awarding institution -

8 School School of Nursing

9 Department Clinical Nursing Department

10 Level of course Third year BSc

11 Year of study andsemester(s) Second Semester 2017/2018

12 Final Qualification -

13 Other department(s) involved in teaching the course

-

14 Language of Instruction English

15 Date of production/revision 28/1/2018

16. Course Coordinator:

Name: Tagreed Osama Shawashi RN, MSc Faculty Member: Office hours Sunday 10-11 Am ,Wednesday 2-3 Pm Phone numbers (23157 ) Email addresses [email protected]

17. Other instructors:

Name: Name: Wejdan Younes Office hours Sunday (1-2) Monday ( 2-3) Email addresses [email protected] Name Malek AL-Najjar Office hours Sunday ( 1-2) pm , Phone numbers (23127) Email addresses [email protected].;jo Name Soliman Ahmed

Office number 220

Office hours Tuesday(2-3)

Name Nisreen AL-katib Office hours Sunday ( 1-2) pm , Phone numbers (23153) Email addresses [email protected].;jo Name Mohamed AL-naaeem Office hours Sunday ( 1-2) pm , Phone numbers (220) Email addresses [email protected]

mailto:[email protected]



18. Course Description:

As stated in the approved study plan. This course provides the student with the knowledge and skills appropriate for the care of adults who are suffering from critical health conditions, focusing on bio-psycho-social responses to patient with actual critical problems. This course deliberately give the student clinical experience in specialized medical units. As the student is expected to have basic knowledge and skills related to Pathophysiology, treatment modalities, and advanced nursing skills, using the nursing process steps primarily to provide nursing care.

19. Course aims and outcomes: A- Aims: Introduce the Students In Providing Quality Nursing Care For Critically Ill Clients B- Intended Learning Outcomes (ILOs): Upon successful completion of this course, students will be able to…

Intended Learning Outcomes (ILO)

ILO 1: Demonstrate competency in performing and providing the role of a professional nurse in quality care provision for individuals, families, and groups.

Specific Course Objectives 1. Apply comprehensive nursing care for clients in various critical care settings from admission to discharge, according to the learned principles of basic knowledge.

2. Apply comprehensive health assessment for clients with different critical health problems.

3. Demonstrate effectively different nursing skills depending on procedure manual during simulation training & in clinical setting while caring for critically ill clients. 4. Utilize updated evidenced-based practice in caring for critically ill clients with different critical health problems.

5. Formulate Nursing Care Plan (NCP) for critically ill clients in order of priority

Relevant Competency (JNC) Client- centred care, Ethical and accountable practice, Quality improvement, Evidenced-based practice, Safety.

Evaluation Methods Nursing care plan, written exam, clinical performance evaluation, Clinical oral exam, procedure exam.

ILO 2: Apply principles of effective communication with peers, individuals, families, groups, and health care team.

Specific Course Objectives 6. Show professional behaviour in dealing with client, their families' instructor, and health team members.

7. Build health education for clients and their families according to their needs

Relevant Competency (JNC) Professional communication , Ethical and accountable practice

Evaluation Methods Clinical performance evaluation, Heath education form

ILO 3: Utilize critical thinking and problem solving in planning and implementing nursing care for individuals, families, and groups.

Specific Course Objectives 8. Interpret normal and abnormal ECG (basic and advanced changes) for critically ill clients. 9. Analyse arterial blood gases (ABG) readings for critically ill clients.

10. Combine critical thinking and problem solving approach in nursing care for



clients with different critical health problems.

11. Demonstrate effectively different nursing skills depending on procedure manual in caring for critically ill clients

12. Formulate Nursing Care Plan (NCP) for critically ill clients in order of priority.

Relevant Competency (JNC) Safety, Client- centred care, Ethical and accountable practice, Quality improvement, Evidence base practice

Evaluation Methods Nursing care plan, written exam ,clinical performance evaluation ,procedure exam, Clinical assignment

ILO 4: Apply professional standards, values, and behaviours in providing nursing care for individuals, families, and groups.

Specific Course Objectives 13. Show professional behaviour in dealing with client, their families' instructor, and health team members.

14. Adapt clinical training with hospital policies and Jordanian nurses' code of ethics in variance clinical setting.

Relevant Competency (JNC) Professional communication, Ethical and accountable practice

Evaluation Methods Clinical performance evaluation

ILO 5: Demonstrate safety measures to protect self, individuals, families, and groups.

Specific Course Objectives 15.Explain the indications of Emergency drugs & equipment in various critical care settings 16. Apply nursing care for critically ill client pre, during & after cardiac catheterization.

17.Interpret normal and abnormal ECG (basic and advanced changes) for critically ill clients

18. Demonstrate effectively different nursing skills depending on procedure manual in caring for critically ill clients.

19. Apply comprehensive nursing care for clients in various critical care settings from admission to discharge, according to the learned principles of basic knowledge.

20. Apply comprehensive health assessment for clients with different critical health problems.

21. Operate the specialized machines used in various critical care setting.

22. Apply safety measures among critically ill clients

Relevant Competency (JNC) Safety, Quality improvement ,Client cantered care , Ethical and accountable practice

Evaluation Methods Written exam, clinical performance evaluation, Nursing care plan ,procedure exam , clinical exam

ILO 6: Translate organizational, leadership, interprofessional collaboration, and management concepts into nursing care for individuals, families, and groups.

Specific Course Objectives 23. Build health education for clients and their families according to their needs

24. Adapt clinical training with hospital policies and Jordanian nurses' code of ethics in variance clinical setting.



20. Topic Outline and Schedule:

Topic Week Instructor Achieved ILOs Evaluation Methods for ILOs

Reference Reading and Activities

explanation of the course objectives and papers Infection control Mechanical ventilators. Arterial blood gases

First تغريد شواشي

22,8,15 Due Date (3/5) Written exam

Smeltzer, S., & Bare, B., Hinkle, J., & Cheever, K. (2014). Brunner and Suddarth's textbook of medical surgical nursing (13th Ed.). Philadelphia, PA.: Lippincott

ECG analysis Emergency drug Hemodynamic Cardiac Catheterization

Second د.احمد عقل مالك النجار

نسرين الخطيب سليمان احمد

9,3,11,18,27,16

Clinical performance Evaluation Written exam


Orientation to different clinical unites in the hospital According to orientation tool paper Handle client in critical care units

Third مالك النجار تغريد شواشي وجدان يونس د.احمد عقل

نسرين الخطيب سليمان احمد محمد النعيم

1,19,21,22,24 Clinical performance Evaluation Oral clinical exam Written exam


Relevant Competency (JNC) Professional communication, Ethical and accountable practice

Evaluation Methods Clinical performance evaluation, Heath education form

ILO 7: Utilize evidence based practice in providing care for individuals, families, and groups.

Specific Course Objectives 25. Utilize updated evidenced-based practice in caring for critically ill clients in various critical care settings 26. Combine critical thinking and problem solving approach in nursing care for clients with different critical health problems.

27. Demonstrate effectively different nursing skills depending on procedure manual in caring for critically ill clients.

Relevant Competency (JNC) Evidenced-based practice, Quality improvement, Client centred care

Evaluation Methods clinical performance evaluation, Clinical assignment, procedure exam written exam

http://search.barnesandnoble.com/booksearch/results.asp?ATH=Kerry+H%2E+Cheever





Case study discussion according to nursing process for handled client physical examination demonstration according to jarvas book Handle medications appropriately in critical care Demonstrate different listed nursing skills according to kozeir foundation book ( refer to procedure manual )

simulation training

Fourth Fifth

مالك النجار تغريد شواشي وجدان يونس د.احمد عقل


,2,3,4,5,6 7,8,9,10,11,12,13,14,19,20,21,22,25,26,2

-Clinical performance Evaluation -Oral clinical exam -Written exam -Case report


Smith,s, Duell ,D., & Martin,B.,(2014).Clinical Nursing Skills( International Edition, Eighth Edition).UK :Pearson Education Limited.

simulation training Provide health education for clients and their families according to their needs Procedure exam

Sixth مالك النجار تغريد شواشي وجدان يونس د.احمد عقل


2,3,4,5,7, 10,11,12, 18 ,27,22

Clinical performance Evaluation Oral clinical exam Written exam Procedure exam


Final oral exam for the first rotation Handle clients' prior, during, and post cardiac catheterization procedure Submit procedure manual checklist

seventh مالك النجار تغريد شواشي وجدان يونس د.احمد عقل


1,2,3,4,5,6,8,9,10,11,12,13,14,16,19,20,21,22,25,26,27

Oral clinical exam Clinical performance Evaluation







Beginning of the second rotation and orientation to the new wards. Revision for different achieved skills physical examination demonstration Handle medications appropriately in critical care units

Eighth

مالك النجار تغريد شواشي وجدان يونس د.احمد عقل


3,11,13,14,18,21,27

Clinical performance Evaluation


Assign case for

NCP

(2/4)Monday

Assign case for

NCP

(3/4)Tuesday

Provide health education for clients and their families according to their needs Case discussion according to nursing process for handled client Case discussion according to nursing process for handled client Demonstrate different listed nursing skills

Tenth مالك النجار تغريد شواشي وجدان يونس د.احمد عقل


2,4,5,7,10,12,13,14,22

NCP Clinical performance evaluation.


Smith,s, Duell ,D., & Martin,B.,(2014).Clinical Nursing Skills( International Edition, Eighth Edition).UK :Pearson Education Limited.

NCP NCP

due date (9/4 )

Monday)

NCP

due date(10/4 )

Tuesday)

Procedure exam

Eleventh مالك النجار تغريد شواشي وجدان يونس د.احمد عقل


2,3,4,5,10,11,12,18, ,21,2,3,4,5,6,8,9, 10,11,12,13,14, 19,20,21,22,25,26,272,27 1,2,3,4,5,6,8,9,10,11,12,13,14,19,20,21,22,25,26,27 16

NCP Clinical performance Evaluation Procedure exam







Final oral exam (committee) Handle clients' prior, during, and post cardiac catheterization procedure

Twelfth مالك النجار تغريد شواشي وجدان يونس د.احمد عقل


1,2,3,4,5,6,8,9,10,11,12,13,14,19,20,21,22,25,26,

Final oral exam


Final oral exam (committee) Handle clients' prior, during, and post cardiac catheterization procedure

Thirteenth مالك النجار تغريد شواشي وجدان يونس د.احمد عقل


1,2,3,4,5,6,8,9,10,11,12,13,14,19,20,21,22,25,26,27 16

Final oral exam


Written exam (3/5/2018)

Fourteenth مالك النجار تغريد شواشي وجدان يونس د.احمد عقل


1,2,3, 5,7,8,9,10,15,16,17, 18, ,20, 22,23,26, 27

Final written exam Clinical performance Evaluation


21. Learning Methods and Assignments:

Development of ILOs is promoted through the following teaching and learning methods: (Choose from table below)

Learning Methodologies: The following approaches that are guided by Adult Learning Theory will be used to achieve course and clinical objectives related to the ILOs:

Instructional Methods Learning Activities (Examples)

• Direct Instruction • Structured orientation lectures

• Skills and procedures demonstrations

• Indirect Instruction • Evidence-based articles • NCP

• Interactive Instruction • Clinical conferences and Case presentations

• Group discussion

• Experiential Learning • Experiential learning in clinical setting

• Simulation • Independent Study • Clinical Assignments






22. Evaluation Methods and Course Requirements:

Opportunities to demonstrate achievement of the ILOs are provided through the following assessment methods and requirements: Evaluation Methods Exams Assigned Points

Clinical performance Evaluation First Rotations Appendix (1) Clinical performance Evaluation Second Rotations

15% 15%

Procedure Exam First Rotations Procedure Exam Second Rotations

5% 5%

• Assignment( Nursing care plan) : (Due Date): NCP due date (9/4 ) Monday)

NCP due date(10/4 ) Tuesday Rubric: (refer back to Appendix 2) Objective: To improve Quality and safety of nursing care for critical ill clients To apply critical thinking and problem solving approach

10%

Clinical Oral Exam First Rotation : seventh week 12/3-15/3

Appendix (3) 10%

Clinical Oral Exam Second Rotation: Twelfth - Thirteen week (16/4-26/4) committee exam

10%

Final written Exam Fifteenth week (3/5/2018 ) Wednesday 30%

Total 100%

23. Course Policies:

A- Attendance policies:

• Students must attend all classes of this course.

• Any student with absence of 15% of the classes of any course, will not be allowed to sit for the final exam and will be given the university zero (F grade) in this course.

• In the case (b) above, if a student submits an official sick report authenticated by university clinic or an accepted excuse by the Dean of his/her faculty, the student will be considered as withdrawn from the course, and a "W" will be shown in the transcript for this course.

• Students are not allowed to come late to classes. Any student coming late will not be allowed to attend the class and he/she will be marked absent.

B- Absences from exams and handing in assignments on time:

• Failure in attending a course exam other than the final exam will result in zero mark unless the student provides an official acceptable excuse to the instructor who approves a make up exam.

• Failure in attending the final exam will result in zero mark unless the student presents an official acceptable excuse to the Dean of his/her faculty who approves an incomplete exam, normally scheduled to be conducted during the first two weeks of the successive semester.

• Assignments and projects should be submitted to the instructor on the due date.

C- Health and safety procedures:

Students should comply with the Faculty of Nursing policies regarding pre-hospital training immunizations. Students should comply with the training areas policies regarding infection control, general precautions, and patient isolation.



D- Honesty policy regarding cheating, plagiarism, misbehaviour:

Cheating, plagiarism, misbehaviour are attempts to gain marks dishonestly and includes; but not limited to:

• Copying from another student’s work.

• Using materials not authorized by the institute.

• Collaborating with another student during a test, without permission.

• Knowingly using, buying, selling, or stealing the contents of a test.

• Plagiarism which means presenting another person’s work or ideas as one’s own, without attribution.

Using any media (including mobiles) during the exam

• The participation or the commitment of cheating will lead to applying penalties

according to the University of Jordan Students’ Discipline rules and regulations No. (94,

49, 47,27, 29): http://units.ju.edu.jo/ar/LegalAffairs/Regulations.aspx

•

E- Examination Instructions for Students

• Bring with you full exam requirements (blue pen, pencils, sharpener, eraser, calculator etc.), borrowing from others is not allowed.

• Do not bring any material related to the exam

• Do not bring your mobile phone to the Exam room

• Be in the exam room at least 10 minutes before exam starting time

• It’s not allowed to enter the exam room late. In case of coming late you have to contact the course coordinator immediately

• It’s not allowed to leave the Exam room before the end of the END OF AT LEAST ONE-THIRD OF THE EXAM TIME.

• Write your name and university number on the exam paper and computerized sheet using Blue pen only.

• Use pencil ONLY to shade your answers on the computerized answer sheet.

• Do not leave examination room except under exceptional circumstances at the discretion of the Senior Invigilator and you should be accompanied by an invigilator, if needed.

• For Re-exam issue refer back to the university rules.

http://units.ju.edu.jo/ar/LegalAffairs/Regulations.aspx



F- Grading policy:

A grade of (D) is the minimum passing grade for the course.

Mark Range Grade 0-39 F

40-49 D-

50-55 D

56-59 D+

60-63 C-

64-67 C

68-70 C+

71-74 B-

75-77 B

78-80 B+

81-83 A-

84-100 A

G- Available university services that support achievement in the course:

School of nursing laboratory

University Transportation

24. Required equipment:

Clinical settings equipments procedure manual Stethoscope, note book, torch (pen light), pen & pencil, Watch.

Simulation lab equipment 25. References:

A- Required book (s), assigned reading and audio-visuals: Smeltzer, S., & Bare, B., Hinkle, J., & Cheever, K. (2014). Brunner and Suddarth's textbook of medical surgical nursing (13th Ed.). Philadelphia, PA.: Lippincott

B- Recommended books, materials, and media: Lewis, S., Heitkemper, M., Dirksen, S., O’Brian, P., &Bucher, L. (2014). Medical surgical nursing: assessment

and management of clinical problems (9th. Ed.). St. Louis, MI: Mosby. C-Smith,s, Duell ,D., & Martin,B.,(2014).Clinical Nursing Skills( International Edition, Eighth Edition).UK :Pearson Education Limited. C- Electronic resources Electronic resources are available on: http://ju.coe.deep-knowledge.net/resources

*Examples of available resources on the deep knowledge web site of the University of Jordan e-library:

EBSCO host A to Z; Elsevier clinical key; Pub med; Science Direct; Sage Journals, Springer link, Scopus, etc.


http://ju.coe.deep-knowledge.net/resources



* Dear student you are deeply encouraged to log in the http://ju.coe.deep-knowledge.net/resources page and establish your private user name and password and activate your account, so that you shall be able to use all those available knowledge, books and evidence based electronic resources. Relevant Website and Journals

• Database Website

• You can contact course coordinator at Faculty member website and E-learning.

26. Additional information:

Students will be divided into groups with two rotations. Clinical settings will be: The University of Jordan Hospital, and Al-Basheer Governmental hospital. Students will be guided in each area by specific clinical objectives for that area.

Name of Course Coordinator: -------------------Signature: ------------------------- Date: -------------------------

Head of curriculum committee/Department: ------------------------- Signature: ---------------------------------

Head of Department: ------------------------- Signature: ---------------------------------

Head of curriculum committee/Faculty: ------------------------- Signature: ---------------------------------

Dean: ------------------------------------------- -Signature: ---------------------------------

Copy to: Head of Department

Assistant Dean for Quality Assurance Course File

http://ju.coe.deep-knowledge.net/resources



Appendix (1)

Adult Health Nursing (2) clinical

Second Semester 2017/2018

Clinical Evaluation Tool

Student name : ……………………….

Instructor name :……………………......

Clinical area /rotation :…………………

Evaluation mark (15 )…………….

Evaluation Grade System (Rating Scale *)

Zero: Unsafe clinical practice, continuous assistance

1: Needs Improvement, mostly unsafe and regularly need assistance

2: Performs as expected for this level, safe but still need infrequent assistance

3: Exceptional performance - consistently exceeds expectation, safe, rarely need assistance

N/A Not applicable or Performance Criteria not appropriate for this clinical setting

I Knowledge Base and cognitive skills score

0 1 2 3

A) Define disease process

B) Summarize pathophysiology of the disease process

C) Interpret diagnostic criteria

D) List risk factors and manifestations

E) Explain the rationale for therapy e.g., medication;

its action, side effect, nursing implications.

F ) Compare the client's condition/pattern of recovery with

that associated with the diagnosis

G ) Interpret changes in the client's condition:

• Laboratory data.

• Diagnostic (CT SCAN, ERCP….).

H) List the potential complications associated with the

patient's diagnoses and describe preventive measures.

I ) Relate the patient's condition to the evidence-based

practice









II. Nursing process Score

0 1 2 3

A) Formulate a complete nursing data via Subjective and

objective data

B) Formulate nursing diagnoses a according to NANDA

using PES (problem related to etiologic evidenced by

signs and symptoms)

C) Prioritize nursing diagnoses according to ABC system

(airway, breathing, circulation

D) Formulate short-term goal for each nursing diagnosis.

Using SMART criteria

E) List an appropriate planned nursing intervention for

his/her client with rationale.

F) Implement actual nursing intervention.

G) Record the patient’s response to care using

appropriate medical terminology.









III . Interpersonal Relationships Score

0 1 2 3

A) Build a therapeutic relationship with patient and family.

B) Adhere to clinical training rules (see attached papers

C) Prepare weekly clinical objectives using SMART criteria,

including 3 domains of learning (physical exam, knowledge and

skills)

D) Apply patient health education related to disease process,

therapeutic regimen, life style modification.

E) Build a collaborative relationship with instructor, peers, and

health care members.

F) Control emotions despite stressful situations.









IV . Professional behavior and sense of responsibility

Score

0 1 2 3

A) Show evidence of preparation for clinical

assignments.

B) Prove initiatively for independent learning activities

C) Identify strengths, weakness and learning needs with

the instructor.

D) Discuss and participate in learning activities during

bed side discussions and conferences.

E) Apply all of the delegated responsibilities.

F) Improve performance according to suggested

instructions and accept instructor notes

G) Show commitment to notify instructor in advance

about tardiness or absenteeism

H). Adhere to hospital policies and Jordanian nurses'

code of ethics. ( CPR ,Client Confidentiality

I). Submission of case report









V . Psychomotor skills Score

0 1 2 3

A) Show adequate environment preparation

(privacy, clean surrounding, proper lights, patient

positioning

B) Verified the correct patient using two identifiers.

C) Introduce yourself to the client

D) Explain the procedure for the client

E) Prepare equipment correctly and adequately

F) Adhere to safety measures such as infection

control (hand washing, sterility, proper disposal of

equipment)

G) Demonstrate competent and safe performance of

the procedures

H) Document procedures appropriately.

I) Discuss and Report abnormal findings to

assigned staff.

Instructor comments

……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

……………………

(Student score -----*15 /120)

Instructor signature: ………………. Student signature: ………



Appendix (2)



Nursing Care Plan

Instructions

1. This is the form of Nursing care plan in Adult (2) course & is the only allowed form for this

course

2. Only hand writing using dark ink pen , allowed Don’t type Nursing care plan ( you will get zero

mark)

3. Using abbreviations not allowed

4. Using symbols not allowed (- ,_ ,/ , X )

5. Heath assessment describe finding don’t use normal , good bad ,abnormal terminology

6. Diagnostic Evaluation (Lab results, MRI, CT, ECG, etc….) according to the hospital polices

7. Add References for medications profile

8. Write at least (3) nursing diagnosis completely with Functional Health Pattern, Evidenced

By/Defining Characteristics, goal planned interventions, actual interventions &out com.

9. For emergency students the focus infilling physical exam part will be on the affected system only

10. Attach Evidence Base Research Article related to Client Critical Health Problem

11. Submit in the due date as mentioned in the time table

*Second rotation

Nursing care plan NCP due date (9/4 ) Monday) NCP due date(10/4 ) Tuesday)

11. Submission late from due date student will lose marks (one mark out of ten for each late day)

12. Submission late for more than three clinical days not allowed you will get (zero mark)

13. Mark out of 10 submitted once only




First Semester 2017/2018

Nursing Care Plan

Student Name : Date :

Clinical Area /rotation no. : Evaluator:

Student mark out of 10 ( )

*****************************************************

Nursing Admission Data Base (5%)

Client ........................................... Age : ................ Sex: ..........................

Date of Admission (Transfer) : ..........................Via : .................................

Condition on arrival : Wheelchair.............. Walking............ Stretcher..........

Source of Data:

Spoken language:

Patient education: (1 Mark)

Reasons for Hospitalization : (0 . 5 mark)

Confirmed Diagnosis : ( 1 Mark )

Medication taken at home : ( 0.5 Mark)

Past medical history : (0 .75 Mark)

Past surgical history : ( 0 . 75 Mark)

Family history ( genogramfor 3 generations ) :

(0 . 5 Mark)

ASSESSMENT ( Describe ) (10 Marks)

1. Health Maintenance - Perception Pattern . ( 0 . 5 Mark )

A : Smoking :

B : Alcohol :

C : Allergies (drugs, food, tape, dyes):

2. Activity / Exercise Pattern (Describe activity, feeding, bathing, dressing, toileting, mobility, & using

assistive devices): - ( 1.5 Mark)

3. Nutrition / Metabolic Pattern (Describe): ( 2 Mark)

A : Typical diet at home :

Prescribed diet :

B : Appetite :

C : Nausea :

D : Vomiting :

F : Dysphagia:

G : Weight changes within last 6 months:

H : Dentures :

4. Elimination Pattern : ( 2 Mark)



A : Bowel habits, ostomy, bleeding, assistive devices etc.. :

B : Urinary Habits :-

5. Sleep / Rest Pattern: ( 1 Mark)

6. Cognitive / Conceptual Pattern :- ( 2 Mark)

A : Hearing :

B : Vision

:

C : Vertigo :

D : Discomfort / pain :

7. Coping Stress/ Self Perception Pattern: ( 1 Mark)

A : Major concerns regarding hospitalization of illness :

B : Major loss / change : No ............., Yes (specify)

C : Coping mechanisms :-

PHYSICAL EXAMINATION : ( OBJECTIVE DATA) :- (15%)

1. A) General Survey: ( 1 Marks )

Level of consciousness:

Orientation:

Height Weight Temperature

General Appearance:

B) Vital signs ( with interpretation): (2 Marks)

C) CPOT /RASS if applicable (1Mark)



2. Nutritional - Metabolic Pattern (Describe) : ( 4 Mark )

A : Skin : (1 mark)

B : Oral Cavity : (1 mark)

C: Neck: (1 mark)

D: Abdomen: (1 mark)

3. Activity- Exercise Pattern: ( 5 Marks )

A: Lung and Thorax ( 2 Marks)

B: Cardiovascular: ( 2 Marks (



C: Musculoskeletal: (1 Mark)

4. Cognitive- Perceptual Pattern:- (2Marks )

A: Mental status: (able to calculate, thinking abstractly, memory, etc..):

B: Neurological status:



MEDICATIONS PROFILE ( 10% )

Allergies : ................................................................................................

References: ---------------------------------------------------------------

Drugs and

Classification

( 1 Mark )

Indication for

my Patient

( 2 Mark )

Dose /Route/

Frequency

(1 Mark )

Contra-Indications

( 1 Mark )

Expected side

effects

( 2 Mark )

Nursing

Implications

( 3 Marks )



Diagnostic Evaluation ((Lab results, MRI, CT, ECG, etc….)

Date Test Performed

( 1 Mark )

Normal Value

( 2 Marks )

Patient

Value

( 2 Marks )

Interpretations & Nursing

Implications

(5 Marks)



Functional Health

Pattern

Nursing Diagnosis

( 10 Marks)

Evidenced

By/Defining

Characteristics

( 10 Marks )

Short-Term Goals

(5 Marks)

Planned

Intervention

(With Rationale

)

(15 Marks)

Actual

Intervention

(5 Marks)



The Outcome

(With Rationale)

( 5 Marks)

References:

Instructor comments for Nursing Care Plan

Student mark *10/100= total mark

Instructor signature: ………………. Student signature



Appendix (3)



Oral Clinical Exam

Name of Student: ………………………………… Evaluator:…………………………...

Clinical Area / rotation no. :……………………………………... Date: / /20

Rating Scale *

3. Exceptional performance - consistently exceeds expectation

2. Performs as expected for this level

1. Needs Improvement

0. Unsafe clinical practice


Student score *10/72 = student score out of 10

Items Student Score

0 1 2 3 NA

I Medical diagnosis and Pathophysiology

1 discuss the client's medical diagnoses and chief complain , Verbalizes

accurate information about surgical procedure if present

2 Discuss the definition and Pathophysiology of the disease.

3 Discuss the causes ,risk factors, manifestations ,diagnostic test results,

and medical interventions

4 Relates Pathophysiology of disease(s) to patients’ assessment findings.

II Assessment

1 Perform comprehensive client assessments including history,

subjective (smoking allergy ,diet, elimination ,sleep and pain )

2 List abnormal Objective data in a systematic manner

3 Demonstrates correct techniques for physical assessment based on

patient characteristics

4 Recognizes abnormal client data( using correct terms and description )

III Medication

1 Recall client medication information including classification, route,

frequency& dosage.

2 Discusses the rationale for therapy ( indication)

3 Discuss the side effect of the medications

4 Calculate drug dosages correctly

5 States the nursing implications of the medications by performing

appropriate assessments prior to, during, and after medication

administration

IV Diagnostic tests

1 Recognize normal and abnormal data with unit of measurement

2 Interprets significance of lab and diagnostic tests

3 States the nursing implications of the diagnostic tests

V Needs and diagnosis

1 Formulates appropriate ND with correct problem statement and



Pathophysiology for client needs (Develops comprehensive list of

ND referring to NANDA ) three ND at least

2 Supports ND and problem statement with appropriate abnormal data

obtained from subjective and objective.

3

Establishes priorities of care in meeting identified needs of patients

VI Client Goal

1 Goal stem congruent with problem

2 Goal stem contains all components (SMART criteria)

VII Nursing interventions

1 Prepare clients for interventions/ during assessment

2 Interventions are appropriate, specific and related to parameters or lab

& diagnostic tests

3 Gives rationale for intervention

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Student Signature: ........................................................

Clinical Instructor’s Signature:………………………………………….

Documents

Course Syllabus Course Name: Course Numbernursing.ju.edu.jo/Lists/Courses/Attachments/26/Adult II...Brunner and Suddarth's textbook of medical surgical nursing (13th Ed.). Philadelphia,