Ricciard, Joanna: Pima Medical Institute Associate Degree Nursing Program Clinical Evaluation Criteria Level 2 Professional Sequence II and III

The level II Student will:

1.Describe and demonstrate an advancing knowledge of complex Medical Surgical nursing skills, assessment techniques, nursing procedures, and forms of documentation
2.Identify and discuss moderate to complex topics from Level I objectives as well as adult endocrine, renal, genitourinary, reproductive health systems
3.Identify and discuss moderate to complex geriatric, adult immune, musculoskeletal, and neurological systems
4.Recognize and explain specialty areas of maternal-fetal health, pediatric-adolescent health, mental-behavioral health, and burn care
5.Successfully complete all clinical practice requirements as outlined in the program plan (336 hours)

EVALUATION CRITERIA:
•At least bi-weekly, the instructor will evaluate each performance criteria with a “S” for satisfactory, a “U” for unsatisfactory, a “NI” for needs improvement, or “NA” for not applicable to this student or at this time in the program.
•The student must obtain a satisfactory for the performance criteria in each category.



Preparation for Clinical.
a. Attended pre-conference at assigned time.
Satisfactory
Unsatisfactory


Preparation for Clinical
b. Dress in accordance with Pima Medical Institute Nursing Program Handbook.
Satisfactory
Unsatisfactory


Preparation for Clinical
c. Has appropriate equipment needed for clinicals (example, stethoscope, pen light etc.)
Satisfactory
Unsatisfactory


1. PREPARATION FOR PATIENT CARE
Program Progression Competency:

CARE GIVER
• Develop and implement a basic plan of care utilizing the theory of King & Newman and evaluate patient outcomes
• Organize care for assigned clients, prioritizing care needs
• Demonstrate ethical and responsible behavior
SCHOLAR
• Participate in formal and informal education to gain knowledge and skills necessary to provide safe patient care
Seek educational opportunities to advance knowledge and skills

Complete pre-clinical paperwork and data collection; demonstrate verbally and in writing understanding of patient’s hospitalization including :

• Pathophysiology, reason for admission, patient history
• Drug Cards or Meds Listed for Common/Ordered
Drugs, all current medications and treatments
• Common/Ordered Labs, lab work, radiology reports,
etc.
• Expected Outcomes, patient teaching needs, current
patient snap shot
• Prioritized Needs List



Satisfactory
Unsatisfactory
Needs Improvement
N/A Not Applicable


(NOTE: The student will be sent home if not prepared for clinical and/or patient care)

Comments: (Date Comment Instructor Initials. Document items identified to be lacking for this student’s level of education or items in which extra attention was given to the student during the clinical day.)



2. COMMUNICATION
Program Progression Competency:

COMMUNICATOR
• Demonstrate caring behavior and project a positive
image
• Utilize basic therapeutic communication techniques to
gather assessment data and communicate effectively
with patients, staff, and families
• Utilize cultural, and social awareness as it applies to
patients, families and setting when communicating with
others

a.Communicates to instructor and or assigned staff any concerns regarding critical changes in patient’s condition; reports off prior to leaving unit both during and at end of clinical day.

Satisfactory
Unsatisfactory
Needs Improvement
N/A Not Applicable


b. Establishes rapport with patient, family, and staff members

Satisfactory
Unsatisfactory
Needs Improvement
N/A Not Applicable


c. Documents information in the assigned recording areas as appropriate for the patient:
-Uses black ink
-Uses correct grammar, spelling, and abbreviations
-Uses medically accepted terms
-Corrects charting appropriately
-Charts pertinent information within 30 minutes of med
or treatment
-Charts abnormal findings or changes in condition
-Records the name of the STAFF member to which
observations were made using the first initial, last
name, and title

Satisfactory
Unsatisfactory
Needs Improvement
N/A Not Applicable


Comments: (Date Comment Instructor Initials. Document items identified to be lacking for this student’s level of education or items in which extra attention was given to the student during the clinical day.)



3. PATIENT CARE
Program Progression Competency:

COLLABORATOR/COORDINATOR
• Utilize working knowledge of interdisciplinary team to
establish priorities, to achieve desired patient outcomes
• Participate with the health care team to plan and
implement client care
ADVOCATE
• Identify and support patient rights, nurse’s
responsibilities, and intervene through staff and or
faculty on behalf of patients
• Demonstrate beginning knowledge of health care policy
and the impact on patient care

• Administer medications following the 6 Rights of
Medication Safety, only gives meds under the direct
supervision of the instructor and or designated staff
person.
• Performs nursing care and treatments following proper
technique and within 60 minutes of assigned time.
• Work with nursing staff and fellow classmates with a
team approach to assist others in patient care.
• Provide a safe environment for self, peers, and
patients.
• Conducts self in a professional manner with behaviors
consistent with accountability according to the Nursing
Program Handbook.


Satisfactory
Unsatisfactory
Needs Improvement
N/A Not Applicable


Comments: (Date Comment Instructor Initials. Document items identified to be lacking for this student’s level of education or items in which extra attention was given to the student during the clinical day.)


4. NURSING ASSESSMENT
a. Nursing Assessment:
*Within Scope of LPN or RN Practice*

Program Progression Competency:

TEACHER/COUNSELOR
• Recognize basic level teaching needs in conjunction
with faculty or staff to educate patients, individuals, and
families on basic disease processes, and other
established teaching needs utilizing facility education
assessment

• Completes all sections of the nursing
assessment. Detailed information should
be included. (For example, the color,
consistency amount of trach secretions:
type of wound, exact location, color of
tissue/drainage, amount, odor, etc.)

(Per Site/ Instructor)
• Plans and provides patient & family education
regarding the plan for the day of care, medications,
treatments, hygiene, exercise, etc. per specific patient
needs.


Satisfactory
Unsatisfactory
Needs Improvement
N/A Not Applicable


CRITICAL INCIDENT: Through neglect, commission, or omission on the part of the student to follow standards of practice, harm resulted or could have resulted to the client.

Incident Type:
ME= Med Error DE= Documentation Error
IE= Identification Error O= Other

Comments: (Date Comment Instructor Initials)