Carroll Community College

Department of Nursing
NURS 140 – Nursing Concepts Two
SUMMATIVE Student Clinical Performance Evaluation
Student Sara Brewer Date 2/21/19 Week # 1 Faculty Tammy Keller
S = Satisfactory N = Needs Improvement U = Unsatisfactory NA = Not applicable (*) Critical behavior
Students who meet any of the following criteria will be given a remediation plan and may be placed on probation.
Failure to progress in these areas may result in failure of the course.
-One unsatisfactory grade in a critical behavior -Two needs improvements in a critical behavior
-Two unsatisfactory grades in a non-critical behavior -Four needs improvements
Student Instructor
Self- Eval of
Outcome 1 Eval Student
Apply the nursing process when implementing a plan of care (CO1) S/N/U S/N/U
1. *Prioritizes patient care based on assessment with assistance S S
2. Demonstrates accurate patient assessment skills S S
3. Incorporates data from the patient’s medical record in the provision of care S S
4. Uses patient assessment data to develop individualized plan of care with assistance S N
5. Establishes appropriate nursing diagnoses based on collected evidence and patient S
assessment with assistance S
6. Establishes measurable patient outcomes based on nursing diagnosis with assistance S S
7. Establishes appropriate nursing interventions based on assessment with assistance S S
8. Evaluates patient response to care and revises plan as needed with assistance S S
Student Instructor
Self- Eval of
Outcome 2 Eval Student
Participate in opportunities that promote professional growth (CO2) S/N/U S/N/U
9. Demonstrates professional behavior and appearance S S
10. Seeks input from patient, instructor, and healthcare team in the delivery of patient- S
centered care S
11. *Demonstrates accountability and accepts responsibility for own actions and attitudes S S
12. *Adheres to attendance policy S S
13. Participates actively in all clinical experiences S S
14. Engages in self-reflection and communicates learning needs to instructor S S
15. Completes assignments as required and submits on time S S
Student Instructor
Self- Eval of
Outcome 3 Eval Student
Provide patient-centered care with assistance (CO3) S/N/U S/N/U
16. *Implements appropriate infection control precautions S S
17. Provides culturally sensitive care with assistance S S
18. Documents patient care accurately with assistance N N
19. Uses therapeutic communication skills S S
20. Follows through with all patient care with assistance N S
21. Demonstrates knowledge of medications for assigned patients S S
22. *Administers medication safely using six rights of medication administration N/A N/A
23. Demonstrates caring behaviors S S
24. Uses SBAR to communicate patient status to instructor and healthcare team with S
assistance S
25. Acts as an advocate for patients and families with assistance S S
26. *Demonstrates physical and mental competence S S
27. *Identifies safety concerns and notifies instructor and appropriate healthcare team S
members S
Approved 12/4/14. Revised 12/10/2014; 01/2015; 3/16/18; 1/13/19
 Carroll Community College
Department of Nursing
NURS 140 – Nursing Concepts Two
SUMMATIVE Student Clinical Performance Evaluation
28. Demonstrates time management techniques N S
29. Implements patient and family education S S
30. *Updates instructor and healthcare team regarding changes in the patient’s condition S S
31. *Provides nursing care based on the policies and procedures of the facility S S
32. *Provides nursing care in accordance with the Maryland Nurse Practice Act S S
33. *Adheres to HIPAA guidelines S S
34. *Provides care according to ANA Scope and Standards of Nursing Practice S S
Student Instructor
Self- Eval of
Outcome 4 Eval Student
Plan nursing care based on scientific evidence (CO4) S/N/U S/N/U
35. Justifies patient’s plan of care based on current evidence S S
Student Reflection (Thoroughly answer all questions)
How has this clinical rotation helped to define your role as a nurse? Please explain.

Not only did I need to take care of my patient, I also needed to take care of the parents needs as well. Nursing
is definitely delivering care as a whole to not only the patient but loved ones as well.

Which objective did you accomplish during this rotation? How did you do it?

I participated actively in all of the clinical experience especially when I assisted in the re-insertion of my
patient’s nasogastric tube. In addition, I monitored I’s and O’s, vital signs, skin assessments, ng feeding
disconnection and flushing and assisted in hooking up the feed.

What are your goals for your next clinical rotation?

My goals for my next clinical are to make sure I am aware of the time especially if things need to be done at
certain times. Time management.

Faculty Comments/ Student Learning Goals (Goals must be established even if performance is satisfactory.
If an item was identified as N or U, narrative comments are necessary to clarify student performance along
with goals to improve performance).

Sara made a great pediatric nurse during her clinical experience! It is evident that she is comfortable around
babies and children and she really enjoyed taking care of little ones. Sara was also very comfortable talking to
the patient’s mom who was a nurse herself. She helped provide NG feeds to the patient and checked
placement of the tube, change diapers, and helped clean the patient after an emesis. I agree with your
comment that as a nursing student it is important to know when things are due- feedings, therapies, etc. so
that you can make sure things are done on time. Your documentation, although you did not have much
practice, was accurate. Unfortunately we only had 1 clinical day due to weather so you would have gotten
more practice with looking through the chart, etc.
Great job with your pediatric clinical and I am glad you saw that a big part of pediatric nursing is taking care of
the parents as well.
Student Signature: Sara A. Brewer Date:2/21/2019
Instructor Signature: Tammy Keller Date: 2/21/19

Approved 12/4/14. Revised 12/10/2014; 01/2015; 3/16/18; 1/13/19