NUR 212 Client Care Management Practice I winter 2008[1]x

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1

BELLINGHAM TECHNICAL COLLEGE HEALTH OCCUPATIONS

LPN/RN Option Dev. I.A. Farquhar 8/04

NUR 212

Rev.
S. Bouma 7/09


______________________________________________
__________________________

DEPT/COURSE #:

NUR 212



CLOCK HOURS:


4 credits

(80 hours)


COURSE TITLE:

Client Care Management Practice I


COURSE DE
SCRIPTION:


This course provides the student with an opportunity to examine and evaluate current experience,
determine clinical proficiencies, and through the process of portfolio development, expand
clinical nursing expertise within the acute care setting

(medical or surgical areas, and mental
health).


STUDENT PERFORMANCE OBJECTIVES (Course Competencies):


Upon completion of this course the student will

be able to
:

1. PROVIDER OF CARE AND MANAGER OF CARE



Relate theoretical knowledge
of

nursing to a given clinical situation.



Calculate basic nursing math correctly for safe administration of medication and
intravenous fluids.



Demonstrate progressive skills in communication in order to:

a.

Communicate effectively with pediatric, adult
s
,
mother who is in labor, geriatric
patients and their families as wells as patients demonstrating changes in mental
health status.

b.

Communicate effectively with members of the health team, instructor, and peers,
both orally and in writing.



Use expanded as
sessment to recognize normal and changing patient health status
.



Demonstrate expanded skills in the nursing process by providing patient/family education
based upon assessed learning needs.



Report and document assessment, normal/abnormal observations, and
nursing care
accurately and in a timely manner.



Set priorities and organize patient care.



Implemented a learning plan, based on self evaluation, to expand nursing competence in
a variety of healthcare settings.



Demonstrates assertiveness skills and resolv
es conflicts in appropriate manner
.



D
emonstrate safe and effective nursing practice.



Demonstrates ability to problem solve and make sound judgments in caring for patients
.



Evaluate clinical performance and experiences to determine if the practice standards

were
met.



Develop a portfolio for clinical nursing practice.



2

2. MEMBER WITHIN THE PROFESSION



Performs in accordance with acceptable practice as defined by law.



Follows policies, standards and procedures of:



i)

Clinical facility



ii)

BTC Department
of Nursing



Identifies ethical issues in the clinical setting.



Acts as patient advocate to meet his/her needs.



Seeks opportunity for continued learning, self
-
development
,

leadership
,

and management
skills.



Transition from the LPN role to the RN role

by learning clinical decision making skills
while incorporating critical thinking.


METHOD OF INSTRUCTION:

Discussion

and Clinical
Practice
.


REQUIRED STUDENT SUPPLIES & MATERIALS:



WAC 246
-
840
-
575 (3): For Registered Nurse Programs, (f).



WAC 246
-
840
-
700



NCLEX
-
RN Examination Test Plan, NCSBN,
January 2006
http://www.ncsbn.org/



NLN Roles and Competencies.

(
http://www.nlnac.org/manuals/Manual2004.htm
).



Sparks and Taylor’s Nursing Diagnosis Referenc
e Manual



Davis’s Drug Guide for Nurses



EVALUATION AND GRADING STANDARDS:

Grades will be assigned according to the following criteria:


GRADING GUIDELINES

94%
-

100%

=

A


76
%
-

78.9%

=

C

91%
-

93.9%

=

A
-


72%
-

74.9%

=

C
-

88%
-

90.9%

=

B+


69%
-

71.9%

=

D+

85%
-

87.9%

=

B


66%
-

68.9%

=

D

82%
-

84.9%

=

B
-


63%
-

65.9%

=

D
-

79%
-

81.9%

=

C+


62% and lower = F


3

Grades are calculated from total points possible.

1.

Implementation of Clinical Portfolio




20%

2.

Reflection of Practice through Journal W
riting



10%


3.
Safe and

Effective Nursing Practice




7
0%



In order to pass this
clinical practice
, you must receive a minimum of 80

percent

and have
function
ed

safely in the clinical setting.


METHODS OF EVALUATION

Clinical labs will be grade
d. A student’s grade is based on demonstrating competent clinical
performance and by meeting all clinical objectives satisfactorily. This includes attendance,
professional competency and behavior, and paperwork submitted. A failure
is below 80%.



Individual clinical objectives will be developed
by the

s
tudent and used through the clinical
experience
. A self
-
evaluation of
student’s

clinical performance will be completed to help assess
areas of
strengths and weaknesses.


Written and verbal evaluation
s throughout a student’s
clinical experience

will be p
er
formed by
the
team member

and

instructor
. Evaluation conferences may be held as
necessary

by the
instructor during lab time.


For students encountering difficulty in clinical labs, a performance agreement will be made
between the student and
the

instruct
or
. This agreement will include measures needed to improve
clinical performance.


Failure in the clinical setting will result w
hen the
student

practices in an unsafe manner.
Examples of unsafe practice include but are not limited to: violating safe medication
administration procedures, failing to identify clients, failing to use universal precautions, being
abusive to clients or

staff, violating ANA Code of Ethics or the Patient's Bill of Rights, violating
the client's privacy, being inadequately prepared for procedures, imposing one’s values upon the
client, or denying the client the right to make decisions about his/her own car
e. Failure to
provide a therapeutic environment, inadequate preparation for emergency care ('codes'), or
failure to follow agency policies or procedures will also constitute a clinical failure. See
Definitions of Unsafe Clinical Practice

for further clar
ification

on
the following page.



The final evaluation requires that all objectives have been met and completed in a
satisfactor
y manner. The clinical
instructor will perform the final
evaluation.





4

Definitions of Unsafe Clinical Practice


OVERRIDING
CONCERNS


The student nurse is expected to demonstrate the judgment and behavior necessary to protect

the client from physical and emotional jeopardy and relationships that interfere with comfort and

healing. These areas of potential physical and emotional

jeopardy have been identified as areas

of overriding concerns. These basic behavioral expectations in the areas of overriding concerns

are in effect and, therefore, evaluated throughout the quarter in order to ensure safe practice.

Failure in clinical wou
ld occur because the student: (a) failed in the area of overriding concerns

due to the seriousness of an incident, or (b) demonstrated a pattern of unsafe behavior, despite

guidance of the instructor.


1. Physical Jeopardy:

Physical care is performing nurs
ing intervention that promotes physical well
-
being. Any action
or inaction on the part of the student that threatens the physical well
-
being of a client constitutes
physical jeopardy. For example, failure to identify client

(two identifiers are required, s
uch as
name and birthdate)
, incorrect positioning, unrecognized violation of poor surgical and/or
medical asepsis, such as failure to use universal precautions, failure to wash hands when
indicated, physical abuse and/or misuse of side rails, restraints, a
ssistive devices, equipment, or
improper drug administration.


2. Emotional Jeopardy

Emotional care is assessing the client for values, cultural beliefs, and emotional factors while
caring for a client. Any action or inaction on the part of the student
that threatens the emotional
well
-
being of a client, or increases stress constitutes emotional jeopardy. For example: violation
of privacy, inadequate preparation for a procedure, imposition of own values and beliefs on
clients, denying the client's right
to make decisions about his care, or any applicable
infringement of the Patient's Bill of Rights.


3. Clinical Decision Making

Is a problem
-
solving process by which choices are made in nursing practice

using the steps of the
nursing process.

Unsafe Clinical

decision
-
making is demonstrated when a student makes a
deliberate decision to omit a

critical element within an area of care. Failure in the clinical
decision
-
making area would

occur when a student does not report abnormal findings in a ti
mely
manner, fails to recognize

when prescribed therapy should be omitted, or neglects to report the
rationale for a decision

made.


Please note:

Students are expected to function safely at all times during clinical lab. These are
only some of the example
s of unsafe situations and do not represent all examples that can result
in failure by overriding concerns.







5



ATTIRE

Clean, Department of Nursing uniforms with the
BTC

student name tag and patch
(on the right)

are
to be worn during clinical experience
. The name tag and patch must be visible at all times
when students are on the floor. Students who go to clinical lab dressed inappropriately will be
sent home by the
clinical instructor

receiving an unexcused absence for the day. Please
remember you re
present
Bellingham Technical College

and the profession of nursing.


TARDINESS, ILLNESS, AND UNAVOIDABLE ABSENCES

Students are expected to be at all clinical lab appointments on time. In order for clinical
objectives to be met and for adequate evaluation opportunities to be available, attendance at all
clinical lab experiences is required. Any missed clinical labs m
ust be made up to complete the
hours for the clinical lab at the student’s expense. Absences of more than 10% will be
considered excessive and will prevent the student from progression in the program.



If a student is ill and cannot attend an arranged cl
inical
lab
, it is the student’s responsibility to
phone
your clinical instructor

at

least one hour
PRIOR

to the designated clinical time. The
student is
to reschedule the missed hours
,

if unable to do this the student will be ask to exit the
program.



Pl
ease be
sure to advise your instructor
of any phone
, email

or address changes that may
occur during the quarter.


PREPARATION FOR YOUR CLINICAL DAY

A.

Arrive at your assigned facility on time, well groomed, and
prepared for your


clinical day. You will
need the following items for giving patient care:



Wristwatch with a second hand
.



Stethoscope
.



Appropriate pen for keeping notes
.



Calculator,
to figure IV dosages and rates
.



Resource books such as Davis Drug Guide and Spark’s Nursing Diagnosis
.



Penlight for

assessment
.



Bandage scissors.



Pocket notebook or a “brain”.



B.

Take assignments,
necessary paperwork

and portfolio

to every clinical lab.

C.

Organize and prioritize your day on an on
-
going basis. Keep good notes on your




patients so that yo
u will be prepared for charting and reporting off at the end of your

shift.







6




LEGAL RESPONSIBILITIES



A.


The registered nurse and clinical instructor
must
review

the medical recor
ds of the
client before you are dismissed from the clinical
setting




B.

T
he clinical instructor
must be present when you change IV’s

sites

and hang IV
piggybacks or give IV push medications.




E
.

All
medica
tions

must

be double checked by a RN

or clinical instructor

prior to
administering.



F
.


Follow the
Six

Right rules

when giving ALL medications: The
R
ight patient, the
R
ight medication, the
R
ight time, the
R
ight route, the
R
ight
dosage
, the
R
ight
documentation
. Always

check the patient’s ID armband

and verify birth date

before
giving any
medication.



G
.


You may take phone orders from a physician only if a RN is on an extension

phone,
reads back what has been ordered and then co
-
signs the orders.




H.

Changing dressing
s

on central line and any other complex procedures that you have
not performed prior t
o this clinical experience
requires the

RN or clinical instructor
to
be present.




I.

You must notify your clinical instructor immediately of any situation resulting in an
incident report being filled out due to student involvement or error, or of any unu
sual
event that involves you.



J.

Should you need to leave the floor for any reason, you must inform the RN that you
are working with. Should you
have to leave the building for any reason you must

inform the clinical instructor
.

7

STUDENT ASSIGNMENTS/REQUIREMENTS:


The student will:

1.

A
ssess own practice based on the standards listed in:




WAC 246
-
840
-
575 (3): For Registered Nurse Programs, (f).



WAC
246
-
840
-
700



NCLEX
-
RN Examination Test Plan, NCSBN, January 2006

and NLN Roles and Competencies









(
http://www.nlnac.org/manuals/Manual2004.htm
).

2.

P
repare own clinical learning objectives and continue to meet the objective based on their
own portfol
io.

3.

C
hoose patient assignment
s

and fill out weekly clinical preparation forms. These forms
will be reviewed by instructor at preconference time.

4.

C
omplete self evaluation
twice during the quarter

5.

A
sk the RN to complete clinical evaluation by team member’
s form
.

6.

C
omplete clinical journal reflection questions daily and give to clinical instructor by the
end of the shift.

7.

Complete an alert sheet daily.

8.

P
ass final clinical evaluation by clinical instructor.

.


Purpose of Clinical Portfolio

The portfolio is a
tool

used to validate the acquisition of knowledge and skills congruent with
course expectations and student learning outcomes.


The portfolio provides objective evidence
that students have acquired the content and skills through prior learning and/or prac
tice
experiences.


The decision to accept the documentation provided is based on determination of the
equivalency of this prior knowledge and skills that the student would be expected to demonstrate
at the completion of a specific course.


The portfolio cr
eation process documents the student's
work and accomplishments over an extended period of time. Portfolios are a tool for reflecting
on learning and clinical practice and the discovery of the links between the two.

Guidelines for Portfolio Development

1.

Use a good quality three ring binder for storing of written documents

2.

Portfolio must be typewritten using the following table.

3.

Use a cover page identifying your name and date followed by written assignments and
table of competencies and activities.


Requirements for the portfolio


1.

Write two paragraphs describing your current LPN work activities.

2.

Based on assessment of the RN standard, describe your strengths and describe the


areas that need strengthening during your clinical experiences.

3.

Wr
ite at least two paragraphs describing your vision for being a
registered nurse for the

next 2

years.




8


4.

Portfolio development: The following table contains the nursing competencies that you

will need to perform during your clinical experiences. Each quarter these areas should be

expanded. These competencies are based upon the WAC standards for an RN.

5.

At the end of this experience the students will evaluate their goal/clinical objective
s as a

part of documentation.



Competencies

Goal/clinical
objective

Learning
activities

Knowledge
Base

Documentation

Nursing Process



Assessment



Planning



Intervention



Evaluation





Communication






Client Teaching







Delegation/Supervision







Problem
-
solving/
Decision making






Advocacy







Safe Practice within
the scope of Registered
Nurse






NCLEX study plan







9


Student Self
-
Evaluation


The following pages are the student self
-
evaluation of the clinical experience. The
student

is to fill in form and return to clinical instructor by the beginning of the third day and end
of the final day. Although this is a self evaluation, final evaluation grade is up to the discretion of
clinical instructor.



Student Self
-
Evaluation of Clini
cal Experience


Student ____________________________________________________Date__________


Codes:



S = SATISFACTORY: Meets clinical performance objectives at a level commensurate with theory and experience
in the program. Functions adequately

with
minima
l

direction and guidance. Meets all critical performance
objectives. Seeks assistance when it is needed. Seeks suggestions and benefits

from constructive criticism.

U = UNSATISFACTORY/UNSAFE: Is deficient in meeting clinical performance objectives at a lev
el
commensurate with theory and experience in the

program. Needs frequent guidance and detailed instruction. Is
unable to consistently apply theory to clinical practice. Is unsafe (see overriding

concerns).

NI = NEEDS IMPROVEMENT: Clinical performance


assisted frequently with directive and supportive cues,
needs to
move toward being efficient and
more independent.


Write the above code for your performance in column provided. Make appropriate comments in
th
e third column to provide examples of experiences which support the evaluation in the second
column. Provide supporting documentation if appropriate and remember to take into
consideration the WAC’s and the NCLEX Test Plan.


Experience

KEY

Specific example
s of instances demonstrat
ing

competence or lack
there of.


Nursing Process




1. Assessment:

Collects data from a variety
of sources in order to identify nursing
diagnoses.




2.
Planning:

In collaboration with client
and family, develops plan of care to include
problem identification, nursing
interventions, setting of priorities, needed
services of other health care providers, and
outcome criteria. States appropriate
rationale for interven
tions



3.
Intervention:

Provides nursing
interventions safely and competently,
according to a plan and established
priorities.



4.
Evaluation:

Evaluates effectiveness of
nursing interventions. Revises plan as
necessary.










10

Experience

KEY

Specific examples of
clinical competenciescompeten

Client T
eaching:


1.

Identifies educational needs of the client and/or family.




2. Teach
s

appropriate information related to
identified
,social,cultural and

education needs
.




3.

Evaluates

effectiveness of the teaching activity.



Delegation/Supervision




1. Makes appropriate assignments after making an
assessment of the abilities of the staff.




2. Provides instruction as necessary.




3. Supervises and evaluates
performance of person to
whom the tasks were delegated.



Critical Thinking/Clinical Decision
-
Making


1. Identifies client care problems.




2. Identifies a number of possible solutions to the
problems

integrating other members of the healthcare
team as indicated.




3. Selects an approach to solving the problem and
provides rationale for the selection.




4. Evaluates the effectiveness of the selected solution.




5. Integrates theory with the
care of the client.



Professionalism:




1. Exhibits ethical standards that are compatible with the
nursing profession.






11

Clinical Evaluation by Team Member


The registered nurse is to evaluate the student’s performance. This is to provide immediate
feedback
on the

student
’s

performance. It is the responsibility of the student to ask the
registered nurse to evaluate his or her performance. The student is to

give this form daily to the
clinical

instructor
. This is part of the student’s clinical grade in determining safe nursing care.


CLINICAL LAB PERFORMANCE

Communication _____

Professional Appearance

____

Client Teaching _____

Physical Assessment ____

Delegation _____

Develop or update patient care plans

____

Documentation _____

Problem Solving/clinical decision making

____

Safe Practice with in the RN Scope _____

Organization/Priority Setting _____



Comments:




S = SATISFACTORY: Meets

clinical performance objectives at a level commensurate with theory and experience in the program. Functions
adequately with minimal direction and guidance. Meets all critical performance objectives. Seeks assistance when it is needed
. Seeks suggestions
a
nd benefits from constructive criticism.

U = UNSATISFACTORY/UNSAFE: Is deficient in meeting clinical performance objectives at a level commensurate with theory and ex
perience
in the program. Needs frequent guidance and detailed instruction. Is unable to co
nsistently apply theory to clinical practice. Is unsafe (see
overriding concerns).

NI = NEEDS IMPROVEMENT: Clinical performance


assisted frequently with directive and supportive cues, needs to move toward being
efficient and more independent.




Satisfac
tory



Needs Improvement



Unsatisfactory


Date_________________________Student’s Signature_________________________________


Date_________________________Registered Nurse’s Signature_________________________















12


FINAL
CLINICAL PERFORMANCE EVALUATION


Student ____________________________________________________Date__________


Codes:



S = SATISFACTORY: Meets clinical performance objectives at a level commensurate with theory and experience
in the program. Functions adequ
ately

with
minimal

direction and guidance. Meets all critical performance
objectives. Seeks assistance when it is needed. Seeks suggestions and benefits

from constructive criticism.

U = UNSATISFACTORY/UNSAFE: Is deficient in meeting clinical performance ob
jectives at a level
commensurate with theory and experience in the

program. Needs frequent guidance and detailed instruction. Is
unable to consistently apply theory to clinical practice. Is unsafe (see overriding

concerns).

NI = NEEDS IMPROVEMENT: Clinical

performance


assisted frequently with directive and supportive cues,
needs to
move toward being efficient and
more independent.


Write the above code for the student performance in column provided. Make appropriate
comments in the third column to provide

examples of experiences which support the evaluation
in the second column.

Experience

KEY

Specific examples of instances demonstrat
ing

competence or lack
there of.


Nursing Process




1. Assessment:

Collects data from a variety
of sources in order to identify nursing
diagnoses.




2.
Planning:

In collaboration with client
and family, develops plan of care to include
problem identification, nursing
interventions, setting of priorities, needed
services of other health care providers, and
outcome criteria. States appropriate
rationale for interven
tions



3.
Intervention:

Provides nursing
interventions safely and competently,
according to a plan and established
priorities.



4.
Evaluation:

Evaluates effectiveness of
nursing interventions. Revises plan as
necessary.







13

Experience

KEY

Specific
examples of instances demonstrat
ing
competence or lack

there

of
.

Or lack there of

Client Teaching:


1.

Identifies educational needs of the client and/or family
,
incorporating social and cultural factors.




2. Develops a plan for teaching that will
answer the needs
identified.



Delegation/Supervision




1. Makes appropriate assignments after making an assessment
of the abilities of the staff.



Critical Thinking/Clinical Decision
-
Making


1. Identifies client care problems.




2. Identifies a

number of possible solutions to the problems

integrating other members of the health care team as indicated.




3. Selects an approach to solving the problem and provides
rationale for the selection.




4. Evaluates the effectiveness of the selected
solution.




5. Integrates theory with the care of the client.



Professionalism:




1. Exhibits ethical standards that are compatible with the
nursing profession.




PASS [ ] *FAIL [ ] (Any
“U”

constitute a failure.)


COMMENTS:





Date


Instructor’s signature
____________________________________




Date



Student’s signature
_____________________________________________







14

Clinical Performance Agreement


BTC Department of Nursing



Student
__________________________

Date_____________________



Area(s) of concern:








Statement of the goal:







Description of the activity to achieve stated goal:







What
resources are needed to reach stated goal:







Time frame to reach stated goal:






Signatures: Instructor_____________________Student_____________________

15

Bellingham Technical College

Department of Nursing

Student Evaluation of Clinical Instructor


Course______
______________________ Clinical
instructo
r_________________________


Quarter: Fall____

Winter____

Spring____


INSTRUCTIONS:

Please choose one number that best describes your experience.


Rate Scale:

4

Strongly Agree

3

Agree

2

Disagree

1

Strongly Disagree


Instructor’s Performance:

Knowledge of the clinical area

4

3

2

1

Enthusiasm

Inspires quality of work

4

3

2

1

Plans clinical experiences considering my individual
needs

4

3

2

1

Encourages questions and comments

4

3

2

1

Stimulated
thought and discussion

4

3

2

1

Respect and concern for student

4

3

2

1

Facilitates my increasing independence in the
clinical setting

4

3

2

1

Clarity in explaining clinical expectations

4

3

2

1

Is available when requested

4

3

2

1

Assist me in finding
my own solutions

4

3

2

1

Timely return of student’s work

4

3

2

1

Offers constructive positive criticism and evaluation

4

3

2

1



What aspects of this
clinical experience

contributed most to your learning this quarter?






What aspects of this
clinical
experience

were barriers to your learning this quarter?






If you marked 2 or 1, please give examples of reason for using these marks. What are your
suggests for improvement?


16

Bellingham Technical College

Department of Nursing

Clinical Facility Evaluati
on by Student


Clinical Facil
ity_______________________
Nursing Unit_______________________________


Quarter: Fall____

Winter____

Spring____


INSTRUCTIONS:

Please choose one number that best describes your experience.


Rate Scale:

4

Strongly Agree

3

Agr
ee

2

Disagree

1

Strongly Disagree


The unit environment was appropriate to your learning needs:

Number of Patients

4

3

2

1

Variety of Diagnosis

4

3

2

1

Equipment

4

3

2

1

Unit Resources

4

3

2

1

The nursing staff maintained open communication
appropriate in meeting your learning
needs

Knowledge level

4

3

2

1

As role models

4

3

2

1

Fostered independence

4

3

2

1

Concern and Respect for me

4

3

2

1

I feel I have benefited from this experience

4

3

2

1








The strengths of this clinical
facility were:







What recommendation for improvement within the clinical facility?






If you marked 2 or 1, please give examples of reason for using these marks. What are your
suggests for improvement?


17

Date



Student Name






CLINICAL LAB WORK SHEET


Room Number


Sex

Code Status

Admission Date


Allergies

Precautions

Diet

Activities

Vital Signs


Oxygen

Intake and Output

Tubes



Weight

I.V.’s



Medical Diagnoses


Chronic Health Problem unrelated to
admission.



Surgeries or diagnostic procedure while in the hospital include dates.



Significant History related to admission. (Signs and Symptoms that cause the patient to be admitted)




Notes: ( e.g. family information and data that will help you
to take care of the patient)






Medications

List medication and times to be given.
Meds must be listed for 24 hours, not just the shift you are
working.
































18

CLINICAL LAB WORK SHEET


Room Number 444
-
1


Sex Male

Code Status
Chemical code

Admission Date 1/21/06


Allergies Penicillin, Zocor, Ampicillin

Precautions: Fall

Diet: Cardiac, NAS

Activities Bathroom privilege with
help

Vital Signs

Every 4 hours

Oxygen 1 L/NC keep O2 Sat above
92 percent

Intake and Output every

4 hours

Tubes Foley



Weight every day
--
210

I.V.’s D5W at tko and Lasix 3 mg/hr.
site right arm

Uses hearing aides

Medical Diagnoses: MI, CHF and Atrial Fib with PVC, CAD


Chronic Health Problem unrelated to admission. Diabetes type 2, COPD, PVD,

Cholelithiasis, CAD, hypertension,
venous umbrella device


Surgeries or diagnostic procedure while in the hospital include dates. Heart Catheter 1/21/06



Significant History related to admission. (Signs and Symptoms that cause the patient to be
admitted)

Was in the mall and developed chest pain mid sternum. Took 3 NTG and pain subsided. Drove home. Laid down
and slept for 2 hours awoke with chest pain unrelieved with NTG. Wife states that pulse was more irregular; up to 90
it normally runs 60
, B/P 160/110, normally 130/70. Took Ativan and MS, pain was not relieved. Called the
ambulance.

12
-
lead ECG showed atrial fibrillation with ST wave changes indicating a MI. Cardiac Enzymes were elevated. Sent
for heart cath.



Notes: ( e.g. family
information and data that will help you to take care of the patient)

Lives with his wife and she is the primary care giver. Has been seeing the cardiac nurse every month for following
CHF and chest pain.

Has been driving and uses canes to walk.

Medicatio
ns

List medication and times to be given.


1600

1700

1700

2100

2100

2100

2100
















Lasix 40 mg. p.o

Digoxin 0.25 mg p.o.

KCL 20 mEq p.o.

Zocor 40 mg p.o.

Cardizem 40 mg. p.o.

Nexium 40 mg p.o.

Surfak 100 mg p.o.


PRN

PRN

PRN

PRN


NTG SL

Ativan

0.5 mg

Morphine 2 mg SL

MOM p.o.




19






Student Name____________________________
Instructor
__________
___________


Steps

S

NP

Comments

Wash Hand




Gather Equipment and prepare tape




Identify Patient
/explain procedure




Assess both arms for best
vein




Clean area using appropriate technique




Apply tourniquet 2 to 3 inches above site




Immobilize vein




Approach the vein at a 15
-
25 degree angle




Insert cannula using sterile technique




Flattened catheter when blood flash




Advance
catheter (not needle) into vein




Released tourniquet




Attached appropriate tubing




Documented I. V. start










































20








Date



Student Name






Care Plan


Assessment

Nursing
Diagnosis

Outcomes

Interventions























































21




22

Neuro/Head

Mental Status:


Oriented (Yes/No) Person


Place


Time


Situation


Alert______ Drowsy


Lethargic

Comatose


Cooperative


Uncooperative_______

Combative___________Others________________________

Memory intact:


Recent


Remote _______


Vision:




Acuity: Clear_____Diminished _____ Blind_____ Which
Eye_________________________






Pupil size: Equal

Unequal


Which Eye____________________________________






Right: Pupil Response: Brisk


Sluggish


Absent ______






Left: Pupil Response: Brisk


Sluggish



Absent ______






Glasses: Yes No Contact lenses: Yes No


Eyes:




Moist


Dry


Sclera: White ___

Jaundiced ____






Color of conjunctiva: Pale


Pink


Jaundiced _____


Hearing:



Right: WNL


Impaired


Deaf


Hearing aids: Yes No






Left: WNL


Impaired


Deaf


Hearing aids: Yes No


Teeth:




Normal


Abnormal


Describe___________________________________






Dentures: No


Upper


Lower


Partial _____






Swallowing problems: Yes


No





Mouth




Mucous Membranes:

Moist


Dry


Color: Pale


Pink ____ Lesions

_____






Describe____________


Chest

Respiratory:


Rate



Depth: Shallow


Deep


Abdominal


Diaphragmatic

Irregular___






Breath sounds: Normal


Diminished


Equal on both sides _____






Lungs clear


Crackles: Fine ___ Coarse ___ Wheezes: Ins


Exp ___






Any 02: Yes


No


Via cannula

Mask


Trach


ET___ Rate/% _O2 sat_






Deep breathing and coughing: Yes


No


Spirometer ______






Cough: Yes


No


Sputum: Yes


No


Quality

Color ____
_______






Chest tube: R ___ L ___ M
___ Suction ___ Gravity __
Drainage:________________


Cardiovascular:


Cyanosis: No


Yes


Where

HR_____ B/P_____







Heart sounds: Strong


Weak


Regular


Irregular


Murmur _____






Pulses palpable: Pedal: L ___ R ___


Radial: L ___ R ___






Telemetry: Yes ___ No ___ Read
ing ___________________ JVD:Yes__No_
_







Other:

__________________________________
___
_______________________

GI

Nausea/Vomiting:


Yes No Describe emesis____________________________________________


Appetite:


Good


Poor


Intake of food: Diet______% of food

Fluids

cc


N/G tube:


No


Yes


Patent


Suction: Intermittent

Continuous

Output ______cc




Character and amount of drainage ___________________________________________


Abdomen:


Soft


Hard


Distended


Nondistended


Tender


Non
-
tender _____






Bowel sounds: Present


Absent


Hypoact
ive________ Hyperactive _______



Date of Last BM_________ Colostomy _____ Color


Consistency ___________



Continent _____ Incontinent_____

BMI




Height______Weight______ pounds/inches squared X 705 =______conclusion_______


Tubes




F.T. ___PEG ___

J. Tube ___

Rate _____ Type of Solution___Intake:__
cc






J.P. ___ Hemovac ___

Describe Drainage___
____________________________






Others__________________________________
____________________________

Torso

Skin:




Moist


Dry


Pink


Pale


Jaundiced _____






Intact


Lesions, rashes, bruises

Describe____
_______________________






Wounds: Where___
___________Dressing dry and intact______Dressing Changed_____






Describe wound__________________________________________________________






Incision: Where______________________Staples ___ Steri
-
Stripe ___ Condition______


23




Turgor: Firm


Dehydrated


Fragile _____






Edema: Yes No Pitting

Trace


+1


+2


+3


+4 ___








Where_________________________________






I. V. Site: ___________________________ I.V. Fluid intake:___________________
cc

Extremities:


Temperature: Cold


Cool


Warm


Hot








Color: Pink


Pale


Cyanotic


Mottled ______






Capillary Refill: Seconds to refill ______






Homan's sign: Positive


Negative _____SCD_____________TEDS_______________


Urinary

GU:




Voiding: Continent______ Incontinent______ Foley: No


Yes


Patent___






Color/clarity


Amount of urin
e _______________

Movement

Musculoskeletal:


Mobility: Ambulatory


Up in Chair


Bedrest _____






Any abnormalities in ROM, Gait, Balance ____________________________________________






Equipment Used____________________________________
Handgrips equal ______________

S
leep/Rest Pattern


Any difficulties: No


Yes


Explain ________________________________________

Cognitive/Perceptual Pattern

Pain:




Overt signs: Yes


No


C/O Pain No


Yes


Location

__________________






Intensity: Scale (1
-
10)


Pain Medication


Results________________

Knowledge Level:


Knows current medical problem and treatment regimen Yes


No ___

Self
-
Perception/S
elf
-
Concept Pattern

Patient appears:


Calm


Anxious


Irritable


Withdrawn


Restless ____






Major stressors

__________________________________________________________________

Needs:




Grief/sadness


Frustration/anger



Fear/anxiety


Hopelessness____ Loneliness____

Role/Relationship Pattern

Language:


English



Other_______________________________________________________________

Speech Problems:


Yes


No


Describe_________________________
_____________________________

Sexuality/Reproduction Pattern






Vaginal/Penile discharge, bleeding, lesions: Yes


No _____






Odor: Yes ___ No ___ Describe _________________________________________________

Coping/Stress Tolerance
Pattern






Any signs of stress: Crying, wringing of hands, clenched fists: Yes


No _____






Any traumatic events in past year: Yes


No _____






Describe _______________________________________________________________________






Ra
te your handling of stress: Good


Average


Poor ____






Family support: Yes


No____




Family/Friends visiting: Yes___ No____

Value/Belief Pattern






Do you observe any implements of religion (Rosary, Bible, Religious Books) Yes


No ____






How can we help you maintain your spiritual strength: Prayer


Call Pastor/Clergy ______







Comments_________________________________________
______











24

Successful IV starts

Student_______________________

Nursing 212

Rhonda Grey RN MSN

Sue Bouma RN BSN CRNI



1.


Date


Gauge


Attempts



2.

Date


Gauge


Attempts


3.

Date


Gauge


Attempts


















25




ALERT SHEET


What are you on alert today
with this patient? (one problem, the one you think is most
important).







What are the important assessments to make?






What complications may occur?






What interventions will prevent these complications?







Were you right?


















26



















REFLECTION THROUGH JOURNAL WRITING


Reflection, or thinking about our experiences, is the key to learning. Reflection allows us to analyze our
experiences, make changes based on our mistakes, keep doing what is successful, and build upon or
m
odify past knowledge based on new knowledge. Reflection also allows us to make connections between
theoretical concepts and experiential learn.


The following are questions that the student will answer daily and hand into instructor at the end of each
clin
ical la
b day. They must be type written
.



1.

Describe
a

problem that that arose during the shift answering the following questions
.


A.

Explain the

c
ircumstances

of this problem

including the steps that you took to



solve the problem.




B.

What
knowledge or resources were required for you to solve the problem?


C.

What influenced your thinking about this problem?


D.

Was the problem solved?



F.

Review the steps of problem solving and then determine if the steps taken were in



priority order.




2
.

Based on your
portfolio
,
describe which competency you were to apply to the clinical

setting.

Give an example.




3
.

Describe your experience in relationship to thoughts
, feelings

and what you learned
?









27

4
.

W
hat concepts

from the theory class were you able to apply

to clinical practice?

Describe
how you applied the concept.






28

Mental Health Clinical Experience


OBJECTIVES

At the completion of this experience, the student will be able to:


1.

Utilize active listening
skills with client.

2.

Apply therapeutic communication skills in initiating a client conversation

3.

Collaborate with the health care team in developing, implementing or evaluating plan of

care.

4.

Discuss the role of the registered nursing as a member of

the mental health care team.

5.

Assess the mental status an
d psycho social status of two
clients.


Required Activities:


Pre Clinical

1.

Review module “Caring for the psychiatric patient” and answer the quiz questions.


2.

Answer the quiz questions for ps
ychotropic medication.

3.

Review chapter on effective communication in your psychiatric nursing book.


Clinical


1.

Perform a mental status examination on two clients. Use the form provided identify the 3
nursing diagnoses as related to the assessment

2.

Perform 2 process recordings. Use the form provided.

3.

T
he student will locate the module on AIMS assessment module and answer the quiz
questions.

4
.

Perform
two

AIMS assessment for client on antipsychotic drugs.

5
.

Participate in at least one group ther
apy session and describe the following.



What type of therapy session?



What nonverbal cues were noted?



Briefly describe the content discussed.


7.

Turn in reflection journal to instructor



Dress Code:


1.

Must wear your name badge.

2.

May dress in casual

clothes in good repair
--
in other w
o
rds not torn or with holes.

3.

No provocative clothing and no showing your waist line

midriff must be covered.

4.

Only single stud earrings. No dangling earrings, bracelets or chains around neck.

5.

No firearms, weapo
ns, valuables, or drugs.








Mental Health Examination


The mental status examination is the recorded observation of the client’s appearance, symptoms, mood and
psychological function. This information can be elicited during the process of the first
interview or during a time
that you are talking with the patient.


29


Student’s Name___________________________________Date____________________


Diagnosis of patient_______________________________________________________


Brief history of signs and symptoms t
hat led to the diagnosis_______________________


________________________________________________________________________


List of medication (both medical and psychiatric drugs)___________________________


_________________________________________________
_______________________


________________________________________________________________________


Appearance and behavior.

Well groomed_______Disheveled______________ Bizzare_________________

Hygiene:
Normal__________Poor__________Others______________________

Affect: Bland____flat_____inappropriate_____depress_______




Anxious_____WNL____pressured______


Stream of Talk

WNL________fast_____slow__________flight of ideas________ coherent____
__

Concise______disconnected word salad______distractibility__________________

Others:_______________________________________


Emotional State:

Mood: Hostile_______,depressed________ Euphoric_________Vegetative________


GI symptoms: diarrhea, constipatio
n, anorexia, weight loss_______________


Insomnia_____


Other_________________________________


Content of thought and fantasy

Concerns_______preoocupations_______topic of conversation__________________

Phobias_________obsessions_________difficulty concent
rating__________________

Hallucinations___________________delusions____________grandiosity___________

Suicidal thoughts_______________________________________________________

Others_________________________________________________________________

























30

Mental Status Examination page 2


Sensorium and Intellect:

Orientation: time______place______person__________situation_________

Memory Remote (use questions regarding date of birth or historical events)__________

Memory Recent (use
questions regarding last 24 hours)___________________________

Retention and Recall: use number forward or backward and see how many they can recall. Educate them in regards
to a medication that they are on and then before you leave ask them a question re
garding the
medication________________________________________________________________________


Intelligence: Knowledge consistent with education and background.________________________________

_____________________________________________________________
___________________


Ability to abstract: Ask question regarding difference such as a child and a midget or similarities such as an ocean
and a river.


Insight:

Understand
ing of
symptoms___________

D
enial of problem________________


Judgment:

Plans for
the future


Motivati on:


Does the client want therapy?______ How is the client participating in
care?_____________________________________________________


Rapport:

Was there any?______________Significant verbal and non
-
verbal cues________________



Nurs
ing Diagnosis (require 3)








31

ABNORMAL INVOLUNTARY MOVEMENT SCALE

AIMS


Examination Procedure


Either before or after completing the examination procedure
observes the patient

unobtrusively,
at rest (e.g., in waiting room)


The
chair to be used in this examination should be a hard, firm one without arms.




1.

Ask patient whether there is anything in his/her mouth (i.e. gum, candy, etc. ) and if there
is to remove it.


2.

Ask patient about the current condition of his/her teeth,

Ask patient if he/she wears
dentures. Do teeth or dentures bother patient now?


3.

Ask patient whether he/she notices any movements in mouth, face, hands, or feet. If yes,
ask to describe and to what extent they currently bother patient or interfere wit
h his/her
activities.


4.

Have patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor.
(Look at entire body for movements while in this position).


5.

Ask patient to sit with hands hanging unsupported. If male, between legs
, if female and
wearing dress, hanging over knees. (Observe hand and other body areas.)


6.

Ask patient to open mouth. (Observe tongue at rest within mouth.) Do this twice.


7.

Ask patient to protrude the tongue (observe abnormalities of tongue movement
.)


8.

Ask patient to tap thumb, with each finger, as rapidly as possible for 10
-
15 seconds;
separately with right hand, then with left hand. (Observe facial and leg movements.)


9.

Flex and extend patient’s left and right arms (one at a time). Note any
rigidity


10.

Ask patient to stand up. (Observe profile. Observe all body areas again, hips included.)


11.

Ask patient to extend both arms outstretched in front with palms.


12.

Have patient walk a few paces turn and walk back to chair. (Observe hands
and gait.) Do
this twice.












32

PROCESS RECORDING



Student’s Name_____________________________________




Date___________
____________________

Diagnosis of
Patient_________________________________




Length of
Intera
ction_______________________
___


OBJECTIVE STATEMENT


Client says and does

Student Thinks and Feels

SUBJECTIVE STATEMENT


Student says and does

Assessment of Interaction































PROCESS RECORDING


33



Student’s Name_____________________________________




Date_______________________________

Diagnosis of Patient_________________________________




Length of
Interaction__________________________


OBJECTIVE STATEMENT


Client says and does

Student Thinks and Feels

SUBJECTIVE STATEMENT


Student says and does

Assessment of Interaction