Care Plan PDF

VN 201L
Fall 2014

1

Southwestern College
Vocational Nursing Program

VN 201L
Introduction to Vocational Nursing I
Fall 2014

Rose Cruz, RN, MSN
Angelia Monroy, RN, MSNc
Anna Curran, RN, MSNc

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Fall 2014
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TABLE OF CONTENTS

Page
Section I
Instructors Information Page
Premise of Critical Thinking
Course Description
Global Course Objectives
Comprehensive Course Objectives
Proficiency to be Demonstrated in Following Procedures
Textbooks
Assignment of Points
Criteria for Evaluation and Grading
Volunteer Hours

4
5
6
6
7
11
12
13
14
15
Section II
Attendance Policy
Clinical Guidelines
Physical Requirements for Patient Care
Journals
Journal - Template
Nursing Care Plan - Application of the Nursing Process
Nursing Care Plan - Guidelines for Written Assignment
Nursing Care Plan - Grading Criteria
Nursing Care Plan - Example
Nursing Care Plan - Organization
Nursing Care Plan Template
Oral Presentation
Oral Presentation Grading Criteria
SBAR - Guidelines
SBAR - Template
2014 National Patient Safety Goals --- Ambulatory
2014 National Patient Safety Goals --- Hospital
2014 National Patient Safety Goals --- Long Term Care
2014 National Patient Safety Goals --- Home Care

17
18
19
20
21
22
24
25
26
27
28
29
30
31
32
33
34
35
36
Section III
Clinical Performance Evaluation

38

Southwestern College recommends that students with disabilities or specific
learning needs contact their professors during the first two weeks of class to
discuss academic accommodations. If a student believes they may have a disability
and would like more information, they are encouraged to contact Disability Support
Services (DSS) at (619) 482-6512 (voice), (619) 207-4480 (video phone), or email at
DSS@swccd.edu Alternate forms of this syllabus and other course materials are
available upon request.
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SECTION I

Instructors Information Page
Premise of Critical Thinking
Course Description
Global Course Objectives
Comprehensive Course Objectives
Proficiency to be Demonstrated in Following Procedures
Textbooks
Criteria for Evaluation and Grading
Total Point Breakdown
Volunteer Hours

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PROFESSORS/INSTRUCTORS

Professor: Rose Cruz, RN, MSN
Office: 4125
Phone: (619) 216-6750, ext. 4430
Cell: (619) 708-9156
Email: rcruz@swccd.edu
Office Hours: Monday 0900-1400 at campus office

Professor: Angelia Monroy, RN, MSNc
Office: 4125
Phone: (619) 216-6750, ext. 4431
Cell: (619) 607-7578
Email: amonroy@swccd.edu
Office Hours: Monday 0900-1400 campus office

Professor: Anna Curran, RN, MSNc
Cell: (619) 977-4283
Email:

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PREMISE OF CRITICAL THINKING

"Critical thinking is a process that challenges an individual to use reflective, reasonable,
rational thinking to gather, interpret and evaluate information in order to arrive at a
judgment. The process involves thinking beyond a single solution for a problem, focusing
on the best alternatives, and deciding which solution provides the best outcome."

Critical thinking is an essential component to have to function as a nurse. An emphasis will
be made throughout the nursing program to facilitate the skill of critical thinking to nursing
students.

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VN 101L - COURSE DESCRIPTION

Course Description: 2 units
Companion laboratory to VN 101 including patient care experiences in selected clinical
settings.
Includes application of therapeutic and professional communication, nursing process,
charting, and fundamental patient care skills.

VN 101L GLOBAL COURSE OBJECTIVES

Measurable course objectives and minimum standards, as determined
by standards set by the instructors, at 75% Proficiency for a grade of
"C":
1. Student will describe and demonstrate procedures related to patient comfort,
cleanliness, activity, nutrition and elimination.
2. Student will collect and analyze data on patients height, weight, and vital signs
3. Student will describe and apply principles of medical asepsis and infection
control in the clinical setting.
4. Student will recognize patient safety hazards and maintain a safe environment
for the patient.
5. Student will identify and use therapeutic communication techniques,
incorporating diversity and life span development in the communication.
6. Student will recognize and discuss the varied roles of the two types of nurses in
the clinical setting.
7. Student will describe and demonstrate patient physical assessment utilizing the
nursing process.
8. Student will describe and demonstrate proficiency in performing nursing skills in
the clinical setting.
9. Student will utilize critical thinking and clinical judgment in application of the
nursing process
10. Student will collect data and accurately define and utilize the nursing process in
revising a plan of care. Assessment (data collection) nursing diagnosis (in
collaboration with the RN), planning, implementing and evaluating.
11. Student will be able to demonstrate the ability to manage care in the clinical
setting for assigned patient(s).
12. Student will be able to demonstrate professional responsibility in the clinical
setting.

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VN 201L - COMPREHENSIVE CLINICAL OBJECTIVES

At the conclusion of this clinical rotation, the student will be able to:

Provide complete care for 3 assigned clients with self-care deficits incorporating
procedures and appropriate documentation which the student has mastered

Demonstrate the following skills as it pertains to each system:
1. Utilize standard precautions in all daily care.
2. Perform a head to toe assessment on a client.
3. Assess the clients psychological status.
4. Assist the client in therapeutic diet planning according to their disorder.
5. Assist and prepare a client for diagnostic procedures
6. Recognize significant lab results & report accordingly.
7. Document according to facility policy.
8. Document informed consents
9. Teach client measures output to maintain fluid electrolyte balances
10. Document accurately I & O.

Demonstrate nursing care for clients with deficits of the integumentary system.
1. Perform skin assessment
2. Observe care of clients with burns.
3. Care for clients with pressure ulcers.
4. Perform dressing changes using clean and sterile technique
5. Perform a suture/staple removal
6. Care of a patient with a decubitus ulcer
7. Observer a debridement procedure
8. Administer topical treatment for skin disorders
9. Demonstrate nursing interventions to prevent skin breakdown
10. Care for a client with an infectious skin disease using the procedure for contact
isolation

Demonstrate nursing care for clients with deficits of the musculoskeletal system
1. Perform a general assessment of a client for the musculoskeletal system
2. Provide proper care for a client in a cast.
a. Perform CMS checks
3. Measure and apply TED hose
4. Apply ace wraps
5. Assist client with can, crutch, walker or wheelchair
6. Accompany a client to physical therapy
7. Care for a client with Rheumatoid Arthritis Instruct patient on purpose of medication,
diet and exercise to prevent and treat osteoporosis
a. Teach clients ways to prevent or minimize the effects of osteoporosis
8. Care for a client who has had back surgery
a. Assess motor and sensory abilities on a client with a spinal injury.
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b. Perform log rolling
c. Dressing changes
d. Apply back brace
9. Provide appropriate nursing care for a client with a fractured hip.
a. Place abductor pillow
10. Provide common nursing interventions for the client having joint replacement therapy
a. Care for a patient who has had joint replacement surgery using CPM machine
b. Empty Hemovac
11. Care for a patient who had had an amputation
a. Perform dressing and stump care
b. Plan care for a client with an amputation that promotes optimal healing
12. Provide proper care for the client in traction
a. Demonstrate application of moist and dry heat and cold to injured tissues
13. Demonstrate nursing interventions for client with a fracture
a. Demonstrate necessary actions to deal with common complications of the
fracture
14. Demonstrate common nursing interventions for sprains and strains
15. Perform pin-site care

Demonstrate nursing care of the client with cardiovascular and peripheral vascular
disorders
1. Collect subjective and objective data for clients with cardiovascular disorders
2. Collect subjective and objective data for client with peripheral vascular disorders
3. Perform an overall pulse assessment of a client.
4. Obtain an apical pulse with 100% accuracy.
5. Assess a client for chest pain.
6. Provide competent care to a post-surgical cardiovascular client.
7. Provide competent care to a client receiving rehabilitation status post cardiovascular
insult to the cardiovascular system
8. Create nursing care plan for a cardiac rehab client incorporating:
a. Diet plan
b. Discharge plan
c. Client education
9. Measure extremities for edema and document
10. Provide care for clients undergoing diagnostic tests and monitoring for
cardiovascular disorders
11. Provide nursing care for client under-going diagnostic testing and monitoring for CV
disorders
12. Assist in the nursing care for a client undergoing invasive procedure
13. Contribute to the care planning and provide individualized nursing care for clients
with coronary heart disease and dysrhythmia

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Prepare a nursing care plan for a client with either a primary or secondary diagnosis
of on the conditions listed below
1. Blood dyscrasia
2. Anemia
3. Coronary artery disease
4. Angina pectoris
5. Myocardial infarction
6. Cardiac arrhythmias
7. Infections of the heart
8. Hypertension
9. Arteriosclerosis
10. Venous thrombosis
11. Varicose veins

Demonstrate nursing care for a client with endocrine disorders
1. Perform a glucoscan.
2. Report on the action of insulins, short, intermediate, and long acting.
3. Assess for signs and symptoms of insulin reaction.
4. Assess for diabetic ketoacidosis.
5. Prepare and deliver a client education plan for diabetic care.
6. Prepare and deliver a client education plan for insulin administration

Demonstrate nursing care for a client with a disorder of the neurological system:
1. Perform neurological checks & document.
2. Assess clients motor skills.
3. Use the Glasgow Coma Scale to determine level of consciousness.
4. Assess signs & symptoms of increased intracranial pressure.
5. Provide seizure precautions.
6. Assess and monitor motor & sensory functions of a client with a CVA.
7. Provide safety precautions for a client.

Demonstrate nursing care for a immunosuppressed client
1. Collect objective and subjective data for clients with disorders related to hematologic
and lymphatic systems
2. Provide care for a client in protective isolation
3. Provide clients with immunological precautions when appropriate.
4. Provide care to clients with AIDS.
5. Recognize the clinical manifestations of benign and malignant tumors.
6. Assist with preventative nursing actions before chemotherapy treatment
7. Demonstrate proper precautions when caring for a client with radiation implants.
8. Demonstrate precautions when caring for the immunosuppressed client.
9. Participate in team meetings when caring for a client in rehabilitation.
10. Provide emergency treatment for a client experiencing a hypersensitivity reaction

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Demonstrate nursing care for a client with reproductive system deficit.
1. Identify data gathering standards for the male and female reproductive system
currently used methods of prevention of STDs
2. Assess vaginal Discuss common disorders of the male and female reproductive
system
3. List common sexually transmitted diseases (STDs)
4. Describe discharge and describe in documentation
5. Insert vaginal suppositories or other medications by physician order
6. Develop a nursing care plan for a client with a reproductive system deficit
7. Document using descriptive terms

Apply mental health principles to the client in a subacute care or long term care
facility.
1. Provide for clients' psychosocial needs following Maslow's hierarchy
2. Recognize defense mechanisms used by the client
3. Recognize the signs of client drug abuse
4. Recognize a nurse at risk
5. Use the nursing process in caring for a client with a mental illness

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VN 101L PROFICIENCY TO BE DEMONSTRATED IN
THE FOLLOWING PROCEDURES

1. Handwashing
2. Donning personal protective equipment
3. Donning and removing sterile gloves
4. Establishing and maintaining a sterile field
5. Using a bed or chair monitoring device
6. Assessing vital signs: body temperature, pulse, respirations, blood pressure
7. Bathing clients
8. Providing hair care
9. Providing oral care
10. Removing, cleaning and inserting hearing aids
11. Changing an occupied and unoccupied bed
12. Focused physical assessment by body system
13. Providing passive range of motion (PROM)
14. Moving client in bed
15. Transfer a client
16. Hoyer transferring lift
17. Assisting a client to walk
18. Providing a back massage
19. Feeding a client
20. Weighing and measuring a client
21. Monitoring blood glucose
22. Inserting and removing NG tube
23. Administering tube feeding
24. Measuring intake and output
25. Inserting and removing urinary catheters
26. Collecting a clean-catch urine specimen
27. Wound dressings
28. Obtaining a specimen or wound drainage
29. Irrigating a wound
30. Obtain urine specimens (routine & clean catch).
31. Provide care for client with a urinary drainage system
32. Insert a Foley catheter (male & female using sterile technique
33. Perform straight cauterization (male & female).
37. Informed consent
38. Medication administration (oral, topical, otic, ophthalmic, rectal, SQ, intranasal;
reconstitution; 10 Rights
39. Dosage Calculation Conversions
40. Reading drug labels
41. Parenteral drug administration
42. MAR documentation
43. Electronic drug dispensers
44. Disposal of medication waste
45. Postmortem care

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TEXTBOOKS

Required:

Timby, B. (2013). Fundamental Skills and Concepts in Patient Care (10
th
edition).
Philadelphia: Lippincott, Williams & Wilkins.

Timby, B. (2013). Workbook for Fundamental Skills and Concepts in Patient Care (10
th

edition). Philadelphia: Lippincott, Williams & Wilkins

Timby, B. & Smith, N. (2014). Introductory Medical-Surgical Nursing (11
th
edition).
Philadelphia: Lippincott, Williams & Wilkins

Timby, B. & Smith, N. (2014). Workbook for Introductory Medical-Surgical Nursing
(11
th

Stedmans. (2012). Medical Dictionary for the Health Professions and Nursing (7
th
edition).
Philadelphia: Lippincott, Williams & Wilkins

Nursing 2014. Drug Handbook (34
th

Dunning III, M.B. & Fischback, F. (2011). Nurses Quick Reference to Common Laboratory
& Diagnostic Tests (5
th

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ASSIGNMENT OF POINTS

Computation of academic grades is based on a point system. Each quiz, test and
assignment is given a specific point value. Please see point distribution. It is strongly
advised that the student keep track of her/his points.

TESTS/ASSIGNMENTS
POSSIBLE
POINTS
ACTUAL
POINTS
WEEK 2
Journal #1 5
WEEK 3
Journal #2 5
WEEK 4
Journal #3 (to include experience in SIMs LAB) 5
SIMs LAB #1 Group 1 10
WEEK 5
Journal #4 5
WEEK 6
SIMs LAB #1 Group 2
WEEK 7
Journal #6 5
Careplan (due 2
nd
clinical day) 25
WEEK 8
SIMs LAB #1 Group 3
WEEK 9
Journal #8 5
WEEK 10
SIMs LAB #2 Group 1 10
WEEK 11
Journal #10 5
WEEK 12
SIMs LAB #2 Group 2
WEEK 13
Journal #12 5
Oral Presentation 25
WEEK 14
SIMs LAB #2 Group 3
WEEK 15
Journal #14 5
WEEK 16
Journal #15 5

TOTAL POINTS 145

NOTE: You will receive 10 points for completing the homework, attending and successfully
completing the simulation lab day.
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CRITERIA FOR EVALUATION & GRADING

The student must meet the clinical objectives listed above. In addition, the following points
are assigned for the clinical rotation. ALL assignments must be completed and submitted,
or:
1. A point may be deducted for lateness, and/or
2. A make-up assignment may be given.

You MUST achieve at least 75% of the points (109 points) to pass the clinical course:
Points
Journals (15 at 5 points each) 75
Nursing Care Plan 25
Oral Presentation
SIMs (2 at 10 points each)
25
20_
TOTAL 145

The criteria and/or templates for these assignments can be found on Blackboard.

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VOLUNTEER HOURS

As part of the learning experience at Southwestern College, students are required to
complete at least four (4) community service/volunteer hours each semester. These hours
provide a great opportunity to give back to the community while experiencing personal
fulfillment.

Refer to VN Handbook for guidelines and required paperwork.

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SECTION II

Attendance Policy
Clinical Guidelines
Physical Requirements for Patient Care
Journals
Journal - Template
Nursing Care Plan - Application of the Nursing Process
Nursing Care Plan Guidelines for Written Assignment
Nursing Care Plan - Grading Criteria
Nursing Care Plan Example
Nursing Care Plan - Organization
Nursing Care Plan Template
Oral Presentation
Oral Presentation Grading Criteria
SBAR - Guidelines
SBAR - Template
National Patient Safety Goals Ambulatory
National Patient Safety Goals Hospital
National Patient Safety Goals Long Term Care
National Patient Safety Goals Home Care

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CLINICAL/SIM ATTENDANCE POLICY

Each student is expected to attend every clinical/SIM lab in which he/she is registered.
Frequent absences interfere with student learning; therefore, a student will fail from the
class/clinical, if recorded absences become excessive.
1. Students may be dropped from clinical (and subsequently the course) for excessive
tardiness, for failure to attend clinical the first day, or any time during the semester if
the total number of absences exceeds twice the number of hours the clinical meets
per week.
2. If a student is late (any time after the clinical has scheduled to start) three (3) times, it
will count as one absence.

In the VN program, there is no differentiation between excused and unexcused absences.

A student is to call the lead instructor if lateness or absence to a class/clinical is anticipated.
When a student is unable to attend clinical or skills lab**, ADVANCE NOTIFICATION
MUST BE GIVEN TO THE CLINICAL VN FACULTY AND THE FACILITY TWO HOURS
PRIOR TO THE START OF THE CLINICAL unless directed otherwise by the clinical
instructor. The student should be sure to get the name of the individual with whom they
leave a message.

IF A STUDENT IS ABSENT FROM A CLINICAL DAY, a make-up clinical or equivalency
may be deemed necessary at the discretion of the faculty team members. The STUDENT
IS RESPONSIBLE for arranging the make-up clinical or equivalency with the clinical
instructor WITHIN ONE WEEK following an absence. Failure to do so may result in
initiation of the Nursing Program disciplinary process. The faculty will determine the make-
up that is required to be completed by the student.

If the student is inappropriately dressed, this includes missing name badges. (Refer to VN
Uniform Policy). They will be sent home and that will count as an absence.

Classroom hours and clinical hours will be recorded separately per semester

** NOTE: Skills Lab is treated as a clinical day.

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CLINICAL GUIDELINES

The student is expected to arrive 15 minutes prior to the start of the shift, in uniform
(including badge) and with your nursing tools. Please review the VN Student Handbook.
You are NOT allowed to miss any clinical days. Any absence needs to be made up. How
the hours will be made up will be at the discretion of the clinical instructor. The make-up
hours may be completed in a clinical site, simulation lab, skills lab, by written assignment,
or a combination. You MUST notify your instructor and the clinical facility if you are going
to be absent TWO HOURS prior to the start of the shift.

THREE tardies (which includes arriving late or leaving early) equal ONE clinical absence.
Your instructor reserves the right to dismiss you from the clinical session if you are more
than 15 minutes late, if you missed shift report, and/or if you are not in the appropriate
uniform. This will equal an absence.

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PHYSICAL REQUIREMENTS FOR PATIENT CARE

Nursing students must be able to do total patient care in all nursing areas without physical,
emotional or psychological limitations. Written documentation of complete recovery from
any previous injury and/or illness must be provided. Following is a brief description of the
type of activities that students will perform while working with patients in the hospital.

1. Moderate to heavy lifting and carrying (20-40 pounds).

2. Pushing, pulling, bending and kneeling around patients using various types of
hospital equipment such as wheelchairs, gurneys, lifting devices and specialized
beds.

3. Fine motor dexterity using both hands while preparing medications and manipulating
a variety of instruments and assessment devices.

4. Rapid mental processing and simultaneous motor coordination.

5. Extensive periods of walking and standing.

6. Visual discrimination including depth perception and color vision.

7. Ability to hear the spoken word in settings where other sounds are present.

8. Working with hands in water (frequent hand washing is required).

9. Working with various materials and substances to which some individuals may be
allergic.

10. Casts, splints, braces are not allowed in the clinical setting.

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JOURNALS

A journal is formatted to help you increase your learning ability, improve communication
and critical thinking skills and to foster personal growth.

It is an introspective assignment in which you record your thoughts, feelings and
experiences related to your clinical experience of the past week. It is hoped that both you
and your instructor gain insight into your experiences in the clinical setting. The insight
gained may help both you and your instructor in facilitating your clinical experiences to best
meet your needs. It also allows for a noncritical dialogue between and your instructor about
your clinical experience.

Journals will not be accepted past the due date (as set by the instructor), and the student
will receive a score of 0 (zero) for any journal that is submitted past the due date.

Subject and format of journals may be changed at clinical instructors discretion.
Clinical Instructor will provide students with notice of change in format at beginning
of clinical shift.

*Note: Up to one (1) point will be deducted
for spelling and grammar

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JOURNAL - TEMPLATE

STUDENT: INSTRUCTOR:
DATE: FACILITY:
GRADE:

Discuss one of your client's MEDICAL diagnoses and how your patient's current
care correlates with theories/facts from your text or lecture. (1 pt) Document
reference (in APA format)

Discuss a nursing intervention YOU performed today or an interaction that you had
today which helped you meet a course/clinical objective. (1 pt)

Discuss an aspect of the nursing care that you delivered today that you can improve
upon. Be specific about HOW you would improve in the future. (Unless you are
perfect, "I wouldn't improve anything I did today" is not an acceptable answer.) (1
pt)

Please share an event that occurred in clinical, either positive or negative (Any
issues with staff? Did you make a mistake? Did you have a difficult interaction with
a client? Did you get to do/ observe something interesting?) (1 pt)

What skills did you observe/perform this week?

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APPLICATION OF THE NURSING PROCESS:
NURSING CARE PLAN

I. Utilize critical thinking and clinical judgment in application of the nursing
process:
A. Assessment:
1. Performs assessments appropriate to the course.
2. Recognizes significant assessment data.
3. Anticipates complications.
4. Detects changes in client condition.
5. Analyzes lab values and diagnostic tests.
6. Growth and development; includes cognitive, psychosocial, moral,
personality
7. Subjective data
8. Objective findings; includes diagnostic data
9. Characteristic findings
10. Environmental factors
11. Nursing diagnosis or potential for diagnosis after analysis of assessment
data
12. Potential problems
B. Diagnosis:
1. Develops NANDA nursing diagnoses.
2. Prioritizes nursing diagnoses.

C. Planning:
1. Develops nursing interventions and outcomes.
2. Prioritizes care for the day.
3. Applies critical thinking skills.
4. Etiology of disease process
5. Predisposing factors
6. Risk factors
7. Individual needs
8. Ethical/cultural issues
9. Set effective goals
a. Client will states expected change"
b. Must be acceptable to client and nurse
c. Realistic and measurable
d. Realistic time frame
e. Identifies components for evaluation

D. Implementation:
1. Assists in delivering plan of care/health promotion teaching.
2. Performs skills appropriate to the course (see skills checklist).
3. Provides safe, efficient, organized nursing care.

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4. Reviews medications :
a. Researches medication ordered, noting indications for use,
recommended dosage, contraindications, and side effects.
b. Compares physicians order to MAR and label on bottle/vial.
5. Involves client and family in care.
6. Demonstrates therapeutic communication with assigned patients, staff,
and peers, utilizing assertiveness where appropriate.
7. Reports significant information to staff and instructor in an accurate and
timely manner.
8. Utilizes evidence-based practice.
9. Delivers culturally sensitive care.
10. Teaching/counseling (ambulatory or hospital)
11. Appropriate referral of patient
12. Notification to appropriate agency
13. Nursing considerations
14. Nursing interventions
15. Nursing care specific to condition or disease process; includes preventive
measures
16. Nursing actions that reflect goals

E. Evaluation
1. Continuously evaluates client's condition and response to treatment/
interventions.
2. Suggests modifications to nursing care plan as needed.
3. Evaluates effectiveness of client teaching.
4. Is family/patient compliant with teaching plan?
5. Have injuries/complications been prevented?
6. Has the patient regained optimal functioning?
7. Have symptoms been relieved/reduced?
8. Is family/patient coping appropriately?

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GUIDELINES FOR WRITTEN ASSIGNMENT: NURSING
CARE PLAN

Written Assignment Points: (25 points)
Due: 2nd clinical day of Week 7 (Submit electronically to clinical instructor)

Directions:
1. Identify the main Medical Diagnosis
2. Based on the medical diagnosis, develop a prioritized list of the top three NANDA
nursing diagnoses for your patient.
3. Place the top priority diagnosis as #1 and develop your care plan for that nursing
diagnosis.
4. The care plan MUST be computer generated (download template from Blackboard).
5. Utilize the Example of What Info Goes in Each Nursing Care Plan Section,
Organization of Nursing Care Plan and Application of the Nursing Process
handouts to develop your nursing care plan.
6. Develop realistic goals/outcomes (goals/outcomes must state a time frame).
7. Nursing interventions must include:
a. Time frame - how often the specific nursing action will be taken, i.e. q4h.
b. The rationale for nursing interventions (references must also be
documented).
8. Refer to the Nursing Care Plan Grading Form for the grading criteria, and include
this grading form when you turn in your assignment.
9. Use as many pages as needed to complete your care plan.
10. Care plans may be submitted to your clinical instructor UP TO ONE WEEK
BEFORE the due date for preliminary review. The care plan will be returned to you
for corrections and the final draft MUST be resubmitted by the final due date.

** NO LATE CARE PLANS WILL BE ACCEPTED!! **

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NURSING CARE PLAN GRADING FORM

Student Name: Date:
Patient Diagnosis: Total points: _____/25 total pts

COLUMN I:
DATA ORGANIZATION AND COLLECTION (3 points)
YES NO COMMENTS POINTS
Subjective Data
Objective Data
Cluster/group data

COLUMN II:
NURSING DIAGNOSIS (4 Points)
NANDA approved diagnosis
Related to statement
As evidenced by statement
Specific to patient

COLUMN III:
EXPECTED OUTCOMES ARE: (5 Points)
Reasonable
Patient-centered
Measurable
Time-frame stated
Specific to patient

COLUMN IV:
INTERVENTIONS REFLECT: (5 Points)
Assessment of nursing diagnosis
Specific interventions to meet outcome
Patient/caregiver learning
Assessment of client/caregiver learning
Multidisciplinary team consultation
Time frame stated
Intervention starts with assessment and ends with teaching

COLUMN V:
RATIONALE (5 Points)
Congruent with intervention
References documented

COLUMN VI:
EVALUATION (3 Points)
Outcome status stated
Criteria of outcome stated
References:

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N U R S I N G C A R E P L A N T E M P L A T E

Medical Diagnosis:

Prioritized List of Nursing Diagnoses:
1. Name:
2. Date:
3. Instructor:

ASSESSMENT PLANNING AND IMPLEMENTATION EVALUATION
Data Collection &
Organization
#1 Nursing Diagnosis Expected Goal/Outcome Nursing Interventions Rationale
Evaluation of
Goal/Outcome
Attainment
Subjective:

Objective:

Cluster Data:

References:
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ORAL PRESENTATION

THESE PRESENTATIONS WILL BE DONE IN POST-CONFERENCE
DURING THE THIRTEENTH (13
th
) WEEK OF THE SEMESTER.

Each student will be randomly assigned a topic to be presented at post-
conference. The topics covered include:
1. Procedures/interventions which you have been aught but may not have had the
opportunity to perform in clinical (and therefore may need a refresher).
2. Procedures/interventions (both nursing and medical) that you may NOT have
been taught but that are common and with which you should be familiar.
3. Common lab values which we may not have covered in lecture but with which
you should be familiar.

The student will:
1. Research the assigned topic
a. For labs, make sure to address the following questions:
i. What is the purpose of each lab test why are they ordered? What
do they tell the health care provider?
ii. What is the normal range for each value?
iii. What are some common causes of elevated or decreased levels?
iv. Should the lab test be done at a certain time of day?
v. Are there any special prep/instructions for patient prior to the test?
b. For procedures/interventions, make sure to address the following
questions:
i. Why are they ordered?
ii. What does the procedure/intervention entail
iii. Is there any pre-procedure/intervention preparation for the patient?
iv. What does the nurse monitor before, during, and/or after the
procedure/intervention?
2. Give a thorough yet concise 8-10 minute presentation, including audiovisual aids.
3. Provide a 1-page (can be double-sided) quick reference sheet for your
classmates and instructor
4. Provider a typed list of relevant and current (no older than 5 years) references to
the instructor.

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ORAL PRESENTATIONS GRADING CRITERIA

Student Name: _________________________________________________________

Topic: ________________________________________________________________

Date of Presentation: __________________________

Presentation Component Points Possible Points Earned
Student knowledgeable about topic content is
organized, useful and complete
5
Student delivers presentation in a clear manner
is easily heard and understood (does NOT read
the presentation)
5
Audiovisual aids enhance presentation 3
Student encourages discussion with classmates
and answers questions effectively
2
Quick reference sheet well-organized, easy to
read and follow, facilitates learning
5
Presentation is completed with the prescribed
time limit
3
Included typed list of relevant and current
references
2
TOTAL POINTS 25

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SBAR REPORT TO PHYSICIAN ABOUT A
CRITICAL SITUATION

S

Situation
I am calling about <patient name and location>.
The patient's code status is <code status>
The problem I am calling about is ____________________________.
I am afraid the patient is going to arrest.
I have just assessed the patient personally:

Vital signs are: Blood pressure _____/_____, Pulse ______, Respiration_____ and temperature ______

I am concerned about the:
Blood pressure because it is ___ over 200 or ___less than 100 or ___30 mmHg below usual
Pulse because it is ___over 140 or ___less than 50
Respiration because it is ___less than 5 or ___over 40.
Temperature because it is ___less than 96 or ___over 104.
B

Background
The patient's mental status is:
Alert and oriented to person place and time.
Confused and cooperative or non-cooperative
Agitated or combative
Lethargic but conversant and able to swallow
Stuporous and not talking clearly and possibly not able to swallow
Comatose. Eyes closed. Not responding to stimulation.
The skin is:
Warm and dry
Pale
Mottled
Diaphoretic
Extremities are cold
Extremities are warm
The patient is not or is on oxygen.
The patient has been on ________ (l/min) or (%) oxygen for ______ minutes (hours)
The oximeter is reading _______%
The oximeter does not detect a good pulse and is giving erratic readings.
A
Assessment
This is what I think the problem is: <say what you think is the problem>
The problem seems to be cardiac infection neurologic respiratory _____
I am not sure what the problem is but the patient is deteriorating.
The patient seems to be unstable and may get worse, we need to do something.
R

Recommendation
I suggest or request that you <say what you would like to see done>.
transfer the patient to critical care
come to see the patient at this time.
Talk to the patient or family about code status.
Ask the on-call family practice resident to see the patient now.
Ask for a consultant to see the patient now.
Are any tests needed:
Do you need any tests like CXR, ABG, EKG, CBC, or BMP?
Others?
If a change in treatment is ordered then ask:
How often do you want vital signs?
How long to you expect this problem will last?
If the patient does not get better when would you want us to call again?
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VN 201L
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2014 Ambulatory Care --- National Patient
Safety Goals

The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on
problems in health care safety and how to solve them.

Identify patients correctly
NPSG.01.01.01 Use at least two ways to identify patients. For example, use the patients name and date of
birth. This is done to make sure that each patient gets the correct medicine and treatment.

NPSG.01.03.01 Make sure that the correct patient gets the correct blood when they get a blood
transfusion.

Use medicines safely
NPSG.03.04.01 Before a procedure, label medicines that are not labeled. For example, medicines in syringes,
cups and basins. Do this in the area where medicines and supplies are set up.

NPSG.03.05.01 Take extra care with patients who take medicines to thin their blood.

NPSG.03.06.01 Record and pass along correct information about a patients medicines. Find out what
medicines the patient is taking. Compare those medicines to new medicines given to the
patient. Make sure the patient knows which medicines to take when they are at home. Tell the
patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

Prevent infection
NPSG.07.01.01 Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the
World Health Organization. Set goals for improving hand cleaning.
NPSG.07.05.01 Use proven guidelines to prevent infection after surgery.

Prevent mistakes in surgery
UP.01.01.01 Make sure that the correct surgery is done on the correct patient and at the correct place on
the patients body.

UP.01.02.01 Mark the correct place on the patients body where the surgery is to be done.

UP.01.03.01 Pause before the surgery to make sure that a mistake is not being made.

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2014 Hospital --- National Patient Safety Goals



NPSG.01.03.01 Make sure that the correct patient gets the correct blood when they get a blood
transfusion.

Improve staff communication
NPSG.02.03.01 Get important test results to the right staff person on time.

NPSG.03.04.01 Before a procedure, label medicines that are not labeled. For example, medicines in syringes,
cups and basins. Do this in the area where medicines and supplies are set up.



Use alarms safely Make improvements to ensure that alarms on medical equipment are heard and
NPSG.06.01.01 responded to on time.

Prevent infection
World Health Organization. Set goals for improving hand cleaning. Use the goals to improve
hand cleaning.

NPSG.07.03.01 Use proven guidelines to prevent infections that are difficult to treat.

NPSG.07.04.01 Use proven guidelines to prevent infection of the blood from central lines.

NPSG.07.05.01 Use proven guidelines to prevent infection after surgery.

NPSG.07.06.01 Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.

Identify patient safety risks
NPSG.15.01.01 Find out which patients are most likely to try to commit suicide.

Prevent mistakes in surgery
UP.01.01.01 Make sure that the correct surgery is done on the correct patient and at the correct place
on the patients body.

UP.01.02.01 Mark the correct place on the patients body where the surgery is to be done.

UP.01.03.01 Pause before the surgery to make sure that a mistake is not being made.

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2014 Long Term Care --- National Patient
Safety Goals


Identify residents correctly
NPSG.01.01.01 Use at least two ways to identify residents. For example, use the residents name and date of
birth. This is done to make sure that each resident gets the correct medicine and treatment.


NPSG.03.06.01 Record and pass along correct information about a residents medicines. Find out what
medicines the resident is taking. Compare those medicines to new medicines given to the
resident. Make sure the resident knows which medicines to take when they are at home. Tell
the resident it is important to bring their up-to-date list of medicines every time they visit a
doctor.

Prevent infection
hand cleaning.

NPSG.07.04.01 Use proven guidelines to prevent infection of the blood from central lines.

Prevent residents from falling
NPSG.09.02.01 Find out which residents are most likely to fall. For example, is the resident taking any
medicines that might make them weak, dizzy or sleepy? Take action to prevent falls for these
residents.

Prevent bed sores
NPSG.14.01.01 Find out which residents are most likely to have bed sores. Take action to prevent bed sores in
these patients. From time to time, re-check residents for bed sores.

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2014 Home Care --- National Patient Safety
Goals




Prevent infection
hand cleaning.

Prevent patients from falling
NPSG.09.02.01 Find out which patients are most likely to fall. For example, is the patient taking any medicines
that might make them weak, dizzy or sleepy? Take action to prevent falls for these patients.

Identify patient safety risks
NPSG.15.02.01 Find out if there are any risks for patients who are getting oxygen. For example, fires in the
patients home.

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SECTION III

Clinical Performance Evaluation

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VOCATIONAL NURSING PROGRAM
CLINICAL PERFORMANCE EVALUATION

STUDENT NAME: COURSE:
SEMESTER/YEAR: DATES OF ROTATION:
CLINICAL FACILITY: CLINICAL INSTRUCTOR:
ABSENT DATES/HOURS: TARDY DATES/HOURS:
MAKE-UP
DATES/HOURS:
CONTRACTS/COUNSELING:
ASSIGNMENT POINTS: CLINICAL GRADE:

LEVELS OF PERFORMANCE
5 Expert
Consistently performs above expected
level; independent
Satisfactory (S) - all objectives met satisfactorily
4 Proficient
Performs above expected level; usually
independent
3 Competent
Performs at expected level with minimal
faculty guidance
2
Advanced
beginner
Performs at expected level with
continuous faculty guidance
Needs improvement (NI) performance contract given
1 Novice
Unable to perform at expected level even
with faculty guidance
Unsatisfactory (U) unsatisfactory and unsafe performance;
the student is unable to overcome deficiencies identified in
the remediation plan and will not progress to the next course

NOTE: STUDENTS AND INSTRUCTORS put a number for the LEVEL OF PERFORMANCE for each item in the column
under student evaluation and faculty evaluation

CLINICAL COMPETENCY
STUDENT
SELF-
EVALUATION
FACULTY
EVALUATION
COMMENTS
I. PROVIDER OF CARE: Utilizes critical thinking and clinical judgment in application of the nursing process.
Assessment:
1. Performs assessments appropriate to the course.
2. Recognizes significant assessment data.
3. Anticipates complications.
4. Detects changes in client condition.
5. Analyzes lab values and diagnostic tests.
OB

PED

BP

OB

PED

BP

Diagnosis:
1. Compares and contrasts NANDA nursing diagnoses.
2. Selects and relates varied nursing diagnoses to client illnesses.
OB

PED

BP

OB

PED

BP

Planning and Implementation:
1. Selects and evaluates nursing interventions and outcomes.
2. Prioritizes client care.
3. Initiates and evaluates clinical reasoning related to client care.
4. Integrates safe nursing practices in all aspects of care, including
safe medication administration.
5. Documents correctly and on time.
6. Integrates client and family decisions related to the plan of care.
7. Integrates and analyzes therapeutic communication.
8. Integrates evidence-based practice into the plan of care.
9. Incorporates cultural awareness into client care.
OB

PED

BP

OB

PED

BP

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II. MANAGER OF CARE (Evidence-based nursing practice): Identifies and describes the ability to manage care in the clinical setting for
assigned client(s).
Evaluation:
1. Continuously evaluates and interprets clients condition and
response to treatments.
2. Compares and contrasts changes in the nursing care plan related
to client needs.
3. Evaluates and implements need for client teaching.
4. Provides care for the number of clients appropriate for the
semester.
5. Seeks assistance and delegates appropriately.
6. Integrates effective communication techniques to keep staff and
instructor informed.
7. Serves as a client advocate.
8. Maintains client confidentiality.
9. Incorporates and analyzes culturally appropriate plan of care.
OB

PED

BP

OB

PED

BP

III. MEMBER WITHIN A DISCIPLINE (Safety): Demonstrates professional responsibility.
1. Maintains clinical preparedness and promptness, and is
responsible and accountable.
2. Adheres to course clinical guidelines.
3. Adheres to dress codes and conduct codes.
4. Follows agency/school policies and procedures.
5. Adheres to ethical and legal standards; patient safety goals.
6. Recognizes and utilizes appropriate communication style with
others (SBAR).
7. Promotes and maintains support to peers and staff.
8. Utilizes resources for self-development.
9. Evaluates own strengths and weaknesses.
10. Completes assignments on time.
11. Participates constructively in post-conference.
12. Demonstrates professional conduct at all times.
OB

PED

BP

OB

PED

BP

**Remediation Plan: If a student receives a NI (Needs Improvement) or grade of U (Unsatisfactory)
at any time during the course of the semester,
a remediation plan shall be developed, outlining requirements designed to assist the student to
overcome identified deficiencies.

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INSTRUCTOR COMMENTS: (Include any specific verbal coaching, action plans, and/or contracts)

STRENGTHS: AREAS FOR IMPROVEMENT:

STUDENT COMMENTS:

FACULTY SIGNATURE:

________________________________________________________

________________________________________________________

DATE:

__________________

__________________

________________________________________________________

STUDENT SIGNATURE:

________________________________________________________

__________________

DATE:

__________________

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