Ms Careplan

Nurs/nurl 3105 (IEN course)

Summer 2015

1

Patient Care Report Nursing Student ______________________

Date of Care_________________________

Pt. Initials _________ Age _______ Allergies

____________________________

Room Number _____ Gender _____ Code

Status__________________________

Mobility __________ Diet _______ Isolation Precautions

__________________

Toileting __________ Assistive devices

_______________________________________

Admitting Diagnosis / Chief Complaint / Current Diagnosis/ Working Diagnosis

PATHOPHYSIOLOGY OF PRIMARY DIAGNOSIS

Pertinent Medical history

SCHEDULED PROCEDURES/TREATMENTS


Summer 2015

2

VITAL SIGNS + Pain Assessment

Abnormal LAB VALUES Date of lab draw ________________________

TEST Pt. result NORMAL

RANGE

INTERPRETATION - Your best reasoning as to why this

patient has this abnormal test result.

List all meds scheduled to be given during your shift. List any PRN meds you administer.

MEDICATION

Dose/Route scheduled

INDICATION

(why is your patient

taking this med)

Nursing Considerations

including. side effects r/t your patient


Summer 2015

3

ASSESSMENTS by systems

NEUROLOGICAL

CARDIOVASCULAR

RESPIRATORY

GI ASSESSMENT Last BM:

GU ASSESSMENT

MUSCULOSKELETAL ASSESSMENT

INTEGUMENTARY ASSESSMENT

PSYCHOSOCIAL ASSESSMENT


Summer 2015

4

VASCULAR ACCESS (type, location, date inserted/changed; fluids running)

SAFETY / Special CONSIDERATIONS

NURSING CARE PLAN (ADPIE) (focusing on one of the priority

problems)

Problem #1

Assessment Data

Nursing Diagnoses Plan Interventions Evaluation

Related to

As evidenced by

________________

Patient will:

Goal:

Outcomes:

1)

2)

3)

NS will:

1)

2)

3)

1)

2)

3)


Summer 2015

5

Problem #2

Assessment Data

Nursing Diagnoses Plan Interventions Evaluation

Related to

As evidenced by

________________

Patient will:

Goal:

Outcomes:

1)

2)

3)

NS will:

1)

2)

3)

1)

2)

3)


Summer 2015

6

Dominican University of California

CLINICAL EVALUATION Tool

The Student:

1. Does not meet Standard (DNS): Is not yet effective in assessing, observing, recognizing patterns and deviations, or seeking information. Takes an unfocused approach to

collecting and organizing data and requires assistance in diagnosing actual or potential

nursing problems, planning interventions, carrying out skills, and evaluating outcomes.

Shows hesitance in communicating and responding to most clinical scenarios.

2. Meets Standards (MS): Captures obvious patterns, collects and interprets a variety of data, but may overlook some important information. Performs basic assessment,

diagnostic, and clinical skills, but still requires some guidance and direction. Conducts

appropriate follow-up to evaluate the effectiveness of nursing interventions. Shows solid

foundation in leadership and communication abilities, though may be disorganized and

hesitant in some aspects of clinical situations.

3. Exceeds Standards (ES): Effectively assesses, seeks information, recognizes obvious and more subtle patterns and deviations, and plans interventions. Displays confidence and

leadership ability, communicates effectively, and requires guidance only in complicated

cases. Demonstrates proficiency in most nursing skills, and requires minimal prompting

in responding to clinical scenarios Completes timely and effective evaluation of nursing

interventions, and develops and updated plan of care when the need for such

modifications have been recognized.

NURL 3105 CLINICAL EVALUATION

Student: DUC ID:

Semester:

Agency: Instructor:

Advisor:

DNS=Does Not Meet Standards (1)

*MS =Meets Standards (2)

ES = Exceeds Standards (3)

*By the end of the clinical rotation, the student must achieve MS (2), at a developing student

level to meet the requirement for passing.

NATIONAL,

PROGRAM, AND

COURSE

OUTCOMES

CLINICAL PRACTICE

COMPETENCIES

Mi

d

Ter

m

End

Ter

m

Comments

Integration of Care

DUC BSN Program

SLO #1

National BSN

Essential I

Nurl 3105 SLO:

Demonstrates integration of the

theory component of the Nurl3105

course into clinical nursing

practice


Summer 2015

7

Demonstrate

developing

knowledge of key

concepts related to

medical-surgical

nursing, including

safety, infusion

therapy, gas

exchange,

metabolism, cardiac

output, elimination,

perfusion, and

nutrition.

Incorporates learning from prior

nursing and non-nursing

coursework into clinical decision

making, psychomotor functioning,

and interpersonal encounters in

care of the acutely ill adult

Nursing Process

DUC BSN Program

SLO #2

National BSN

Essential II

Nurl 3105 SLO:

Utilize the nursing

process and assess

the effectiveness of

nursing care in

meeting the physical,

emotional, spiritual,

and social needs of

the adult patient in

acute care settings.

Conducts an appropriate focused

(diagnoses-specific) assessment on

every patient receiving care in the

med/surg setting in a timely

manner

Correctly interprets assessment

data (including laboratory or other

diagnostic testing values)

Determines the priority nursing

problems (actual and potential) for

the patient

Begins planning care by

developing a list of appropriate,

individualized nursing

interventions

Discusses rationale for medical

and nursing orders and questions

orders if uncertain

Implements planned nursing

interventions and medically

ordered treatments on time, safely,

and accurately according to

standard facility protocols

Evaluates the effects of

interventions

Responds to changing patient

conditions

Patient Centered

Care

DUC BSN Program

SLO #3

Obtains information about the

patient prior to and during the


Summer 2015

8

National BSN

Essential VIII

QSEN Competency:

Patient Centered

Care

Nurl 3105 SLO:

Apply compassionate

and ethical patient-

and family-centered

care while

communicating

respectfully to

individuals coming

from socio-culturally

diverse backgrounds

period of care

Establishes and maintains

professional rapport with the

patient and the significant other(s)

using principles of therapeutic

communication

Conducts all nursing care with

consideration for patients rights and cultural, spiritual, social,

cognitive, and physical conditions

Informs the patient about plan of

care, including any medications

prescribed or procedures to be

performed

Provides opportunities for patient

to discuss problems, or to raise

concerns about their care

Includes patient (and significant

others if desired by patient) in

individualized care planning

activities

Patient Education

DUC BSN Program

SLO #4

National BSN

Essential VII

QSEN Competency:

Patient Centered

Care

Nurl 3105 SLO:

Assess patient learning needs and

provide primary,

secondary, and

tertiary education.

Assesses the patients current knowledge level, ability, and

readiness to learn, accounting for

the effects of culture, language,

cognitive ability, health condition,

and literacy

Provides effective instruction to

help patients acquire knowledge

and skills

Involves significant family

members in teaching-learning

activities whenever possible

Offers access to additional

resources for ongoing education

and reinforcement in the post-

discharge period

Multi-disciplinary

Communication and

Collaboration

DUC BSN Program

SLO #5

Provides clear, concise patient

report to other members of the


Summer 2015

9

National BSN

Essential VI

QSEN

Competencies:

Teamwork and

Collaboration;

Patient-Centered

Care

Nurl 3105 SLO:

Collaborate with

inter-professional

team members to

meet the specific

needs of patients and

their families as a

developing nursing

student.

healthcare team utilizing SBAR or

other organization standard

handoff tool

Discusses plan of care and with

appropriate staff nurse and clinical

instructor. Asserts own

perspective in patient care

discussions with team members

Provides on-going communication

with the staff nurse regarding any

identified changes in patient

condition

Participates in intraprofessional

team activities through

information-giving, participatory

decision-making, and, if

necessary, reporting any concerns

regarding patients status or care

Delegates appropriately to other

team members when assistance is

needed

Requests help from instructor or

relevant team member when in

doubt about any patient care-

related matter

Informs responsible staff nurse

and instructor prior to leaving the

patient care area

Documents patient assessment

data in a complete and timely

fashion and completes all required

documentation prior to leaving the

unit

Uses appropriate professional

language and tone when managing

conflict

Receives input or constructive

criticism from others without

defensive behaviors

Organizational

Systems, Leadership,

Quality

Improvement, and


Summer 2015

10

Patient Safety

DUC BSN Program

SLOs #6

National BSN

Essentials II

QSEN Competency:

Quality

Improvement and

Safety

Nurl 3105 SLO:

Demonstrate

professionalism,

accountability, and

developing

competency

including leadership

and delegation skills

of the registered

nurse.

Participates in clinical conference

discussions showcasing

experiences of class members to

improve direct and indirect

learning from exposure to multiple

patient care encounters

Safety:

Surveys the patient care

environment to identify and acts to

remove potential safety hazards to

reduce the risk of patient, visitor,

and/or staff injury

Complies with the organizational

standards for safe med/surg

patient transport within and

between units

Demonstrates ability to provide

safe and effective care to multiple

patients or to 1 high acuity patient

Demonstrates ongoing accuracy

with safe medication and fluid

administration practices through

written and practical applications

including:

Demonstrates safe practices

related to medication

administration including: rights,

verification of allergies, two

patient identifiers, read-back

process, and independent double

checks for high-alert medications

Educates patient or patients agent on safety practices when

administering medications.

Evidence-based

Practice

DUC BSN Program

SLO #10

National BSN

Essential IV

QSEN Competency:

Informatics

Nurl 3105 SLO:

Demonstrate

Accurately navigates the

electronic health record or printed

chart to locate and document

information

Verbalizes how the HIPAA

applies to computerized health

information systems and insures


Summer 2015

11

appropriate

competency as a

developing nursing

student with the

application of health

information

technology or

informatics in the

acute care setting.

confidentiality of protected health

information by following agency

protocols

Demonstrates accuracy in using

electronic medication

administration systems

Accesses and evaluates online

patient education materials,

policies and procedures,

Professional Values

and Ethical Conduct

DUC BSN Program

SLO #11

National BSN

Essential VIII

Nurl 3105 SLO:

Demonstrate

professional conduct

to provide a safe

environment in the

acute care setting in

order for patient-

centered care to be

delivered

Exemplifies the standards of the

ANA Code of Ethics including:

Demonstrating professional

integrity, honesty, respect for

persons, and accountability for

own actions

Assuring patient privacy and

confidentiality by accessing and

communicating patient

information within HIPAA

regulations

Providing patient-centered care

with sensitivity and respect for the

diversity of human experience and

the rights of patients and their

families in the adult acute care

setting

Exhibits professional conduct and

accountability by:

Arriving at the assigned clinical

shift on time and prepared to begin

work

Attending every assigned

clinical day

Dressing appropriately

according to DUC dress code

policy

Working within the role of a

nursing student according to DUC

and organizational guidelines

Independently seeking


Summer 2015

12

additional information or

resources to improve knowledge

and/or skill deficits

Managing multiple

responsibilities and completing

tasks within expected time frames

Using clinical time effectively

by seeking learning opportunities,

providing assistance to others, and

engaging in appropriate down-time activities

Showing initiative and self-

direction in selecting patients who

will provide unique learning

opportunities


Summer 2015

13

MIDTERM Comments:

Instructor:

Student:

Student Signature: ________________________ Date: _______

Faculty Signature: __________________________ Date: ________

Total Tardy Shifts:

Total Absent Shifts:


Summer 2015

14

ENDTERM Comments:

Instructor

Student

Student Signature: ________________________ Date: _______

Faculty Signature: __________________________ Date: ________

Total Tardy Shifts:

Total Absent Shifts: