Wimmer, Brittany Summer 2016

Outcomes:

1. Describe and demonstrate an advancing knowledge of complex Medical Surgical nursing skills, assessment techniques, nursing procedures, and forms of documentation
2. Name and discuss moderate to complex topics from Level I objectives as well as concepts, functions and assessment of the age specific endocrine, renal, genitourinary, reproductive systems
3. Name and discuss moderate to complex concepts, functions and assessment of the age specific immune, musculoskeletal, and neurological systems.
4. Name, describe and demonstrate the role of the nurse as advocate, communicator, multidisciplinary team member, patient teacher, provider of patient-centered care, and seeker of knowledge.
5. Successfully complete all clinical practice requirements as outlined in the curriculum completing each step of the nursing process with a major focus on recognizing the need for multiple nursing diagnoses, prioritization and the evaluation and revision of the nursing care plan.

PLEASE PRINT FACULTY NAME BELOW:

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Evaluation Criteria:
• Each week, the faculty member will evaluate each performance criteria.
• A faculty member comment is requested for any area where points are deducted.
• Total Clinical Points possible are 100.
• Students receiving less than 50% of total possible points in any area will need to meet with the clinical instructor to arrange remediation.
• Students receiving less than 50% of total possible points in any area for a second time will need to arrange a meeting with the clinical instructor and the Clinical Director for that area to set up a plan for improvement.
• Students receiving less than 50% of total possible points in any area for a third time must meet with the Nursing Program Director immediately.
• Students receiving less than 25% of total possible points at any time must meet with the Nursing Program Director immediately.
• There are five items that must be performed each and every time. Failure will result in a zero being given for that section. These are noted by an *.
• Students do Pre-lab in NUR212 & NUR222. This must be done the day before clinical in order to allow the student time to complete the Prep Sheet.



STUDENT NAME


DATE OF CLINICAL:


NAME OF FACILITY:


FLOOR / UNIT:


WEEK ___
 
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14


I. Preparation for Clinical: (Maximum 10 Points)
-Pre-clinical Prep completed: Demographics, Reason for Hospitalization, History of Present Illness, Past Medical History, Social History, Pathophysiology, Medications, Allergies, Labs, Additional Assessment Information.

 
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10


COMMENTS:


II. Advocate: (Maximum 5 Points)
-Seeks to advocate for patient, liaisons between patients, family, and other medical disciplines.
-Identifies and actively participates with faculty and/or staff in supporting patient’s rights and nurse’s responsibilities.
-Demonstrates working knowledge of health care policies in order to report and seek resolution in discrepancies in policies and practices related to patient and family well-being.
-Identifies and selects appropriate processes to provide patient care.

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COMMENTS:


III. Communicator: (Maximum 5 Points)

-Demonstrates caring behavior, establishes therapeutic relationships and maintains accurate and effective communication with patients, families, and staff.
-Utilizes cultural, social and confidentiality awareness when communicating with patients, family, staff, and faculty members.
-Practices interacting effectively with other health care team members and instructors.
-Reports changes in patient condition to appropriate staff*.
-Establishes rapport with patients, families, and staff.

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COMMENTS:


IV. Multidisciplinary Team: (Maximum 10 Points)

-Works with hospital staff and fellow classmates with a team approach to assist others to plan and implement patient care.
-Provides a safe environment for patients, families, self, peers and staff.
-Reports to assigned nursing staff prior to leaving unit both during and at end of clinical shift.
-Documents appropriate information in the hospital record (must be reviewed by instructor prior to entering); or documents appropriate assessment information on PMI assessment forms.
-Uses correct grammar, spelling, abbreviations, and medically accepted terms.
-Documentation provides detailed information (color, consistency, type of wound, exact location, drainage, amount, odor, etc).
-Demonstrates working knowledge of interdisciplinary team to establish priorities and achieve desired patient outcomes.

 
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10


COMMENTS:


V. Patient Teacher: (Maximum 5 Points)

-Assesses patients needs for education considering developmental stage, literacy, learning preference, level of readiness.
-Provides patients and families with an explanation of current medical condition including pathophysiology using lay terms.
-Reviews medications with patient prior to administration (why receiving, expected effects, common side effects)
-Reviews upcoming procedures with patients explaining reason for test, what results will show, how long test will take.

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COMMENTS:


VI. Provider of Patient-Centered Care: Procedures (Maximum 20 Points)

-Identifies and selects appropriate processes to provide patient care.
-Performs nursing care and treatments following proper technique and within 60 minutes of assigned time.
-Verbalizes appropriate rationale for planned nursing care.
-Prioritizes patient’s needs based upon Maslow’s Hierarchy.
-Demonstrates organization in the performance of nursing care.
-Performs assessments appropriate for the level of student.
-Only performs invasive procedures in the presence of a licensed RN*.

 
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20


COMMENTS:


VII. Provider of Patient-Centered Care: Medications (Maximum 20 Points)

-Administers medications following the 6 Rights of Medication Safety*.
-Documents all medications given correctly in MAR including proper signature (name, SN, PMI) and RN co-signature if paper charting.
-Utilizes two patient identifiers and verifies allergy information prior to medication administration*.
-Only gives medication under the direct supervision of the faculty member or staff RN*.

 
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20


COMMENTS:


VIII. Seeker of Knowledge: (Maximum 5 Points)

-Identify, develop and implement advanced acute care level teaching needs in conjunction with faculty and/or staff to educate patients and family members regarding acute disease processes, medications, procedures and other teaching needs utilizing facility education assessment.
-Assumes responsibility for own learning, shows initiative by seeking out learning experiences in the clinical setting, participates in clinical activities and clinical conferences.

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COMMENTS:


IX. Completed Clinical Paperwork (Maximum 10 Points)
This typed form is due one week after completion of clinical day.

-Weekly Clinical completed: Demographics, Reason for Hospitalization, History of Present Illness, Past Medical History, Social History, Pathophysiology, Medications, Allergies, Labs, Additional Assessment Information

 
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10


COMMENTS:


X. Presentation (Maximum 10 Points)
- See provided Rubric

 
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10


XI. Professional Standards Deduction (No maximum, may be as low as zero)
- Deductions from Professional Standards Form.



Daily Total (Maximum 100 Points)


COMMENTS:


Clinical Points are awarded as follows for each section:
(93-100%) Outstanding performance: Consistently, skillfully, and with early and minimal instruction is able to meet all objectives
(85-92.99%) Good performance: With limited instruction is able to meet all clinical objectives
(77-84.99%) Minimal performance: With ongoing guidance is able to meet all clinical objectives
(<76.997%) Unsatisfactory performance: Inconsistent in meeting clinical objectives
(0) Unsafe performance:






Michael Kim